"DIFFERENCE BETWEEN BOYS AND GIRLS"
Building Healthy Development in South Australia Associate Professor Victor Nossar Senior Paediatric Consultant Child and Youth Health Children, Youth and Women’s Health Service Importance of the early years Evidence from human and animal studies reveals that nutrition and experience in the early years of a child’s life influence the infant’s brain development. Body functions (such as competence, coping skills, behaviour, and health later in life) are then affected through pathways that involve the endocrine systems, the immune system, and mental processes. While remediable risk factors affecting health occur throughout the life course, childhood is a critical and vulnerable stage where poor socioeconomic circumstances have lasting effects. Follow up through life of successive samples of births has pointed to the crucial influence of early life on subsequent mental and physical health and development. Independent Inquiring into Inequalities in Health Report. London, The Stationary Office, November 1998. Kauai Longitudinal Study: Emmy E. Werner, Jessie M. Bierman, Fern E. French, Ruth S. Smith •Complete cohort of 698 infants born in 1955. •Followed development of these individuals at 1, 2, 10, 18 & 31/32 years of age. •422 infants born without complications, after uneventful pregnancies and grew up in supportive environments. •116 children had physical or intellectual handicaps of perinatal or neonatal origin (diagnosed before 2 years of age). •142 children developed serious learning or behavioural problems (before 10 years of age). •55% of cohort grew up in chronic poverty. Kauai Longitudinal Study Predicting Resilience – Protective Factors • Individual independent, sociable, affectionate, adept at recruiting adult carers • Family four or less children, > 2 years apart, no prolonged separations in the first year • Community informal support at home/work/church, substitute carers Ref: Emmy E. Werner, Jessie M. Bierman, Fern E. French, Ruth S. Smith 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 Key Initiatives For Health Improvement Population Parenting Programs Immunisation Smoking Home Visiting School Connectedness Prevention/ Cessation Early Educational Infant Day-care Maternal Education Breastfeeding 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) At the population-level there is only very weak correlation between traditional health inputs and significant improvement of outcomes for children. Inequality of outcomes: • Families, whose children are most likely to have health problems or illnesses, are often those least likely to be accessed by (or to access) healthcare services. • Services can make the inequalities greater. Cutler DM, Meara E. Changes in the age distribution of mortality over the 20th century. NBER Working Paper 8556. MA, USA, 2001. Marshall M, Leatherman S, Mattke S et al. Selecting indicators for the quality of health promotion, prevention and primary care at the health systems level in OECD countries. OECD Health Technical Papers No.16 OECD, Paris October 2004. Programs to improve health outcomes for populations differ markedly from those designed to assist with the health problems of individuals. 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. Inappropriately focussing on individual level determinants of health while ignoring more important macrolevel determinants is tantamount to obtaining the right answer to the wrong question. (Schwartz & Carpenter. Am J Public Health 1999; 89: 1175 - 80.) Linkage of health outcomes in later life to multiple, interacting early-life influences has resulted in a paradigm shift in population health research, away from simple models of proximal causality and notions of “nature vs. nurture”. Life course epidemiology examines the complex, often cumulative, interplay between the characteristics of the individual (including biological factors, genetic susceptibilities and intra- uterine exposures) and their broader family, social, economic and physical environments. Life course perspectives on health are based on three key conceptual models of human health and development: • The notion of critical or sensitive periods during which certain exposures or environmental conditions are necessary for optimal subsequent growth and development. • Pathways or cumulative exposures emphasises the accumulation of life circumstances that determine subsequent health outcomes. • The importance of the ecological contexts in which individuals develop, and the changing role of these contexts over the lifespan. What can research contribute to healthier development? “Science is just like sex, there may be a practical outcome but that’s not why we do it!” Richard Feynman There seems to be an assumption that a lack of information or evidence constrains our ability to improve health and wellbeing. With the conclusion that more information and more evidence will lead to improved health and developmental outcomes. Concerns: • Much evidence already exists confirming that most of the principal determinants of health are well known. • Most health research dollars continue to be focussed not on the principal determinants of morbidity and mortality of Australians. Concerns: • The principal focus of health research is still on better treatments for affected individuals, on basic science or on more epidemiological descriptions. • Comparatively little research money (or research effort) is expended on trialing ( and evaluating the efficacy of) population-level interventions. 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.) Despite occasional rhetorical interest in wider determinants of health, evidence based assessments are largely restricted to individualised interventions. (Smith, Ebrahim and Frankel. Editorial. BMJ 2001: 322: 184-5.) Obesity in children • Rapid growth in prevalence rates in many developed countries. • Predisposes children to additional risks of disease eg. diabetes mellitus type II. • Correlates with greater risk of adverse health in adulthood. • Social factors appear to play an important role. “The Canadian Institute for Advanced Research … by bringing together the most distinguished thinkers from across Canada and around the world, and providing them with the research time and networking opportunities they need to respond to the scientific and social challenges of tomorrow.” CIAR: The Canadian Institute for Advanced Research. http://www.ciar.ca/ “Teaming up the best researchers across geographic, institutional, and disciplinary boundaries, and by providing this group with leadership and the advice of experts, CIAR creates an arena for exploration and discovery.” CIAR: The Canadian Institute for Advanced Research. http://www.ciar.ca/ Experience-based Brain & Biological Development Program Program Director: Ronald G. Barr, University of British Columbia Investigating the functional linkages between the social and cultural influences experienced by infants and their subsequent biological development ... to discover exactly how, when and under what circumstances differential societal exposures early in life give rise to changes in the neural, endocrine and immunological systems. CIAR: The Canadian Institute for Advanced Research. http://www.ciar.ca/ The unique contribution that South Australia can make. South Australia: • Mainly metropolitan population. • Manageable birth cohort. • Population broadly representative of much of Australia. • Strong tertiary sector. • Unique community-wide child health service – Child and Youth Health. • Unique datasets. Good research is an essential prerequisite of achieving improvements in health and wellbeing, but of itself is insufficient. To get the greatest possible benefit, that knowledge must be applied effectively in programs that focus on improving the health and wellbeing of communities. Where to from here?