1. No category

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2.
Maternal and child health In Chapter One we outlined the importance of the health, education and welfare
sectors in enhancing child development and thus in addressing a key social
determinant of health across the life course.
In the two chapters following this one, regarding the relationships between health and
education and health and welfare, we discuss how primary health care services can
contribute to the success of these other sectors, and how by working with them they
can most effectively achieve their own goals of improving the health of the
community.
However, the logical place to start is with the role of primary health care services in
enhancing the health of mothers and children.
Maternal and child health services are ‘core business’ for the primary health care
sector and the accessibility, appropriateness and effectiveness of these services is
central to the concept of family-centred primary health care.
This focus is directly on the health of children and on mothers because of the
importance of pregnancy outcomes for children. As noted in Chapter One a familycentred approach to maternal and child health requires primary health care services
to focus on the child’s whole family, as the health of all those caring for children is
important to the health of children.
This chapter draws on the extensive literature on maternal and child health but
includes lessons that can be extrapolated to the provision of health services to all
families.32 We will briefly review the evidence on maternal and child health amongst
Aboriginal and Torres Strait Islander communities in Australia, followed by a overview
of the links between child and maternal health and health later in life. We will then
outline a number of key intervention points for primary health care services, together
with the challenges that taking a child development focus and a family-centred
clinical approach raise for this service menu. Last we will summarise a number of
service models which already embody a family-centred primary health care
approach.
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32
This chapter draws upon the summary of the evidence contained in Eades 2004 op cit ), by team member Dr
Sandra Eades, formerly of the Menzies School of Health Research in Darwin. Her paper was part of a series
commissioned by OATSIH; its summary of the literature is a key reference point for those wishing to get an overview
of the literature in this field.
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A summary of the evidence The Health of Indigenous Women and Children It is well known that Aboriginal and Torres Strait Islander women have considerably
poorer general health than other Australian women. This remains true despite recent
gains in Aboriginal women’s health in the Northern Territory, which saw an increase
in Aboriginal women’s life expectancy of almost three years (from 65.0 to 67.9 years)
between 1996-2000 and 2001-2003.33
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Not surprisingly, Indigenous women also have poorer maternal health than other
Australian women: higher rates of chronic disease, poorer nutrition, and higher levels
of genital and urinary tract infections can all complicate pregnancies. Furthermore,
they have higher smoking rates and, while it appears that proportionately fewer
Aboriginal women than non-Aboriginal women drink alcohol, the hazardous use of
alcohol amongst Aboriginal women of child-bearing age is of great concern.34
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They are more likely to become pregnant during the teenage years (22.6% of births,
compared to 4.2% for non-Indigenous mothers35) and are less likely to access early
antenatal care – in the Northern Territory, for example, the proportion of Indigenous
women who received antenatal care in the first trimester of their pregnancy was
around half of that for non-Indigenous women.36
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Consistent with this picture, Indigenous babies are over twice as likely as nonIndigenous babies to be born of low birth weight (12.9% compared with 6.1%37) with
little improvement nationally since 1991.38
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The immediate effects of low birth weight are seen in poorer health in childhood
reflected in a higher risk of dying in the first years of life and a greater susceptibility to
illness and hospitalization.39 Beyond these physical manifestations, low birth weight is
associated with neurological complications and psycho-social and cognitive problems
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33
DHCS (NT Department of Health and Community Services) (2006) NT Health Gains Fact Sheet
http://www.nt.gov.au/health/docs/hgains_factsheet_mortality2006.pdf)
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34
ABS and AIHW (Australian Bureau of Statistics and Australian Institute of Health and Welfare) (2005) The Health
and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples. ABS Catalogue No. 4704.0, AIHW
Catalogue No. IHW14. Commonwealth of Australia.
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36
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37
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ibid.
Eades 2004 op cit.
AIHW 2005 op cit.
38
Plunkett A, Lancaster P & Huang J (1996) Indigenous Mothers and Their Babies, Australia 1991–1993, cat. no.
PER 1 (Perinatal Statistics Series No. 4), AIHW National Perinatal Statistics Unit, Sydney; ABS and AIHW 2005 op
cit.
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AIHW 2005 op cit p37.
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– for example, even in teenage years, children of extremely low birth weight are less
likely to perform well at school.40
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In their early years, Aboriginal and Torres Strait Islander children continue to have
poorer health than the Australian average. While infant mortality improved nationally
in the decade from 1993 (decreasing by around 3.3% per year) the mortality rate for
those in their first year of life remains almost three times that of other Australian
infants (13.0 per 1,000 live births compared to 4.5 per 1,000 live births).41 Note again
that this is despite improvements in infant death rates in the Northern Territory, which
have fallen by over one third in the period 1996-2000 to 2001-2003.42
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A higher burden of hospitalisations in general, and illness from infections, in
particular respiratory infections, typifies the health profile of many Indigenous children
throughout their childhoods.43
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Intervention points for maternal and child health Although best practice primary health care already encompasses many of the
following interventions, making explicit the links between maternal and child health
and the development of a long and healthy life is an important task.
This section seeks to identify the key interventions in the primary health care sector
that are critical to contributing to health throughout the life course. For the sake of
clarity we divide these into two groups: those interventions focused primarily on the
health of the mother (and hence directly or indirectly the baby) before and during
pregnancy, and those focused on the child in its infancy.
Interventions primarily focused on women before and during pregnancy Tobacco Smoking during pregnancy is generally agreed to be the single most important area
for action to improve low birth weight and infant mortality.44 It is associated with
preterm birth, birth anomalies and perinatal deaths45, obstetric complications as well
as increased risk of sudden infant death syndrome, asthma, lower respiratory tract
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40
Saigal S (2000) ‘School difficulties at adolescence in a regional cohort of children who were extremely low birth
weight’ Paediatrics 105:569–74.
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41
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42
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43
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AIHW 2005 op cit p13.
DHCS 2006 op cit.
ibid.
44
AIHW 2005 op cit p 41; Eagar K, Brewer C, Collins J, et al (2005) Strategies for Gain — the evidence on strategies
to improve the health and wellbeing of Victorian children. Centre for Health Service Development, University of
Wollongong p56.
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45
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Walsh R A, Lowe J B, and Hopkins P J (2001) ‘Quitting smoking in pregnancy’ MJA 175: 320–323.
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infections, middle ear diseases and stillbirth.46 In addition, exposure to environmental
smoke among infants and young children increases the risk of respiratory infections,
asthma and otitis media.
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Of particular concern is the high proportion of Aboriginal women who smoke during
pregnancy: the WA Aboriginal Child Health Survey found that 47% of Indigenous
mothers had smoked tobacco during pregnancy, while even higher rates (over 65%)
have been found by at least two other studies.47 Although still serious, maternal
smoking rates in the general community are considerably lower, documented at
around 18%.48
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Primary health care services are well placed to deliver quit smoking interventions for
women in general and pregnant women in particular and a recent review
demonstrated that smoking cessation programs during pregnancy apparently reduce
smoking, low birth weight and preterm birth.49
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Alcohol The consumption of alcohol by pregnant women is significantly related to increased
risk of foetal death and low birth weight, even in cases where the drinking is in the
moderate range.50 This effect can be related to even the earliest weeks after
conception, before a woman may be aware that she is pregnant.
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Aboriginal women are more likely to consume alcohol at a dangerous level than nonAboriginal women: the 1995 National Health Survey, for example, found that 9% of
Indigenous female drinkers were classified as high-risk drinkers, three times the rate
for the population as a whole.51 These drinkers are at the greatest risk of damaging
the unborn child as it develops.
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Brief interventions from primary health care services are effective in reducing alcohol
consumption of women of child bearing age: education, advice and counseling have
been shown to be effective in reducing alcohol consumption in the short term, and
dangerous levels of drinking over the long-term, especially for women who become
pregnant in the period after the initial intervention.52
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Zubrick et al 2004 op cit.
47
de Costa C & Child A (1996) ‘Pregnancy outcomes in urban Aboriginal women’ MJA 164: 523–526; Eades S &
Read A (1999) ‘Infant care practices in a metropolitan Aboriginal population’ Journal of Paediatrics and Child Health
35: 541–544.
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48
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AIHW 2005 op cit p xiii
49
Lumley J, Oliver S, and Waters E (2003) Interventions for promoting smoking cessation during pregnancy
(Cochrane Review). The Cochrane Library. Oxford, Update Software. Issue 1.
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50
Little R E, Asker R L, Sampson P D, and Renwick J H (1986) ‘Fetal Growth and Moderate Drinking in Early
Pregnancy’ American Journal of Epidemiology 123: 270–278; Faden V B, Graubard B I, and Dufour M (1997) ‘The
relationship of drinking and birth outcome in a US national sample of expectant mothers’ Paediatric and Perinatal
Epidemiology 11(2): 167–180.
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51
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Eades 2004 op cit p21.
ibid
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It is also important to observe that Aboriginal primary health care services have often
played important roles in public campaigns around the broader political economy of
alcohol, in particular around availability, licensing and pricing.
Sexual health Poor sexual health, especially sexually transmitted infections, and other genitourinary
infections are associated with preterm and/or low birth weight babies. Indigenous
communities typically have high rates of STIs and other infections. A Western
Australian study showed that just over half of Aboriginal and Torres Strait Islander
women who gave birth to low birth weight babies had a genitourinary tract infection
compared with only 13% of other women.53
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Antenatal care Late presentation for antenatal care is associated with poor birth outcomes among
Indigenous women.54
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While schedules for antenatal visits vary across Australia, the most commonly
accepted standard is monthly visits until 28 weeks, fortnightly visits from 28 to 36
weeks, and finally weekly visits after 36 weeks. There is little published information
documenting the frequency of Aboriginal women’s attendance for antenatal care,
though a study has identified that amongst antenatal attendances at a major urban
obstetric hospital, over one in ten Indigenous women did not receive their first
antenatal care until after 31 weeks of pregnancy.55
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Primary health care services are well placed to identify and reach out to pregnant
women earlier in pregnancy than they may otherwise seek out antenatal care. This
requires both effective population age-sex registers as a cornerstone of good primary
health care management and effective community/family engagement and cultural
safety strategies on the part of the primary health care service.
Family planning Short intervals between pregnancies has been shown to be associated with low birth
weight and preterm births56 as this allows less time for a woman’s body to recover
nutritionally and also because of the added stress of caring for more than one young
child.
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54
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ibid
ibid p6
55
Najman J M, Williams G M, Bor W, Andersen M J, and Morrison J (1994) ‘Obstetrical outcomes of Aboriginal
pregnancies at a major urban hospital’ Australian and New Zealand Journal of Public Health 18:185–9.
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56
Khoshnood B, Lee K S, Wall S, Hsieh H L, and Mittendorf R (1998) ‘Short Interpregnancy Intervals and the Risk of
Adverse Birth Outcomes among Five Racial/Ethnic Groups in the United States’ American Journal of Epidemiology
148:798–805
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Similarly, low birth weight is also associated with a low maternal age. Indigenous
women tend to have children at a younger age than the overall female population,
with more than one in five Indigenous mothers being aged under 20 years, compared
with less than one in twenty-five non-Indigenous mothers.57
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Family planning support and advice are important to enable Aboriginal and Torres
Strait Islander women to make informed decisions about the timing of their
pregnancies. There is evidence that pregnancy counseling services for young
mothers (under twenty years) have a significant positive effect on birth weight.58
Again this is a core primary health care service requiring effective community / family
engagement and effective cultural safety strategies on the part of primary health care
services.
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Nutrition and folate While maternal nutrition is obviously an important determinant of a healthy birth, it
has been the subject of much debate in the literature. It appears that the provision of
nutritional advice alone has little effect, but there is some evidence that actual dietary
supplementation can have an effect for disadvantaged women, although a number of
other problems have been raised with this approach relating to expense and
‘compliance’.59
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A particular issue deserving attention is that of folate (a vitamin found in leafy green
vegetables, fruits, beans and peas) which is essential for the healthy development of
the foetus. It has long been known that folate supplementation significantly reduces
the incidence of neural tube defects amongst babies. Indigenous mothers are about
40% more likely to have a baby with a neural tube defect than non-Indigenous
mothers.
In 1998, folic acid fortification of a large variety of cereal products became mandatory
in Canada. An evaluation of the impact of this measure found that the prevalence of
neural tube defects decreased from 1.58 per 1000 births before fortification to 0.86
per 1000 births, a 46% reduction. The magnitude of the decrease was proportional to
the pre-fortification baseline rate and regional differences in rates of neural tube
defects almost disappeared after fortification began.60
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The mandatory fortification of food with folate is currently a matter being considered
by all Australian Governments.
57
AIHW (Australian Institute of Health and Welfare) (2006) Australia’s health 2006. AIHW cat. no. AUS 73. Canberra:
AIHW.
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58
Eagar et al 2005 op cit p60
59
ibid p58
60
De Wals P, Tairou F, Van Allen M I, Uh S H et al. New England Journal of Medicine. 357(2):135-42.
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Social support and education It has been argued that social support and health education programs directed at
disadvantaged women would be likely to decrease the incidence of low birth weight.
A comprehensive review of such programs (which include counseling, advice, and
support with practical matters such as transport and household tasks) found no
significant reductions in the probability of a low birth weight baby, although some
other psychological benefits for mothers were noted.61 A similar conclusion has been
reached for Indigenous women in Australia.62
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However, social support and health education for pregnant mothers is often provided
embedded within a broader antenatal program – as exemplified by programs such as
the Mums and Babies program in Townsville – and in this context may contribute to
the success of these services. Part of the effectiveness of such integrated programs
may be in the improvement of family engagement with health care services and their
cultural safety. In this sense cultural safety is not just a matter of “safety” in terms of
Indigenous sensitivities but also specifically from the point of view of women and
children. This is one of the success factors cited as a result of the creation of a
specific “mums and bubs” clinic in the Townsville example63 (see below).
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Interventions primarily focused on the child after birth Breastfeeding Breastfeeding is one of the most important health behaviours to impact upon the
survival, growth, development and health of children in their first years. The mother’s
antibodies present in her milk help protect an infant while its own immune system is
developing and has a protective effect against conditions such as diarrhea,
respiratory infection, otitis media, meningitis, sudden infant death syndrome (SIDS),
diabetes, eczema and asthma. It has also been associated with positive health
effects for the mother and improved emotional bonding between her and her baby.64
Breastfeeding has also been positively associated with later child cognitive
outcomes.65
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In Australia, there is conflicting evidence about breastfeeding rates amongst
Indigenous mothers. Some data suggests that the proportion of babies being fully
breastfed at 4 months was lower among those with Aboriginal and Torres Strait
Islander mothers than for those with non-Aboriginal and non-Torres Strait Islander
61
Hodnett ED, Fredericks S (2003) Support during pregnancy for women at increased risk of low birthweight babies.
Cochrane Database of Systematic Reviews, Issue 3.
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62
Zubrick et al 2004 op cit.
63
Dr K Panaretto, personal communication
64
AIHW 2005 op cit p31
65
Pollock J I (1994) ‘Long-term associations with infant feeding in a clinically advantaged population of babies’
Developmental Medicine and Child Neurology 36:426-440
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mothers66. Nonetheless, the Western Australian Aboriginal Child Health Survey
showed that the breastfeeding rate for children at age 12 months was considerably
higher for Indigenous mothers than for Western Australian women in general.67
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Nutrition While breastfeeding is probably the most important activity for ensuring good nutrition
for infants, the introduction of solid foods to infants’ diets and dietary guidelines for
infant feeding are also important.
If infants’ dietary requirements for growth and development in the first year of life are
not met, they can be susceptible to a whole range of illnesses and infections. In
many regions of Australia, Indigenous infants have been shown to have higher rates
of failure to thrive and anaemia.68
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It is important to note that being overweight is also an issue for some Indigenous
children – one study in the Northern Territory found an excess of both underweight
and overweight children in urban areas, while remote areas had a large excess of
underweight children.69 The proportion of over nourished babies (born over 4500g)
has also been reported as an emerging concern in the Torres Strait, a community
with very high rates of Type II Diabetes with very early onset.70
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Programs to monitor infant growth and development, treat anaemia and infections
among and to provide support and advice to parents about infant feeding is an
important part of primary health care. Further, primary health services can play an
important role in advice and activism around the availability of nutritious food,
especially in remote areas where the simple lack of access to nutritious food is often
the base problem which must be addressed if any other intervention is to succeed.
In Chapter Four we will review the evidence on the relationship between child health
and child welfare services. Child welfare staff have sometimes raised concerns that
one unintended consequence of a focus on monitoring infant growth and
development in primary health care services can be an increase in notifications of
disadvantaged children for “neglect” without any concurrent action to improve food
supply, support for family budgeting or other public health measures that might more
effectively address the needs of infants “failing to thrive.”71 This concern has
implications for the skills and clinical approaches of primary health care services.
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AIHW 2005 op cit p33
67
Zubrick et al 2004 op cit.
68
Eades 2004 op cit.
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69
Mackerras D (2001) ‘Birthweight changes in the pilot phase of the Strong Women Strong Babies Strong Culture
Program in the Northern Territory’ Australia and New Zealand Journal of Public Health 25: 34–40
70
Dr Ashim Singha, outreach physician Cairns Base Hospital, personal communication.
71
J Vadivaloo, Child Protection expert, NT, personal communication
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Immunisation Ensuring that all children are appropriately immunised is obviously a key aim of
primary health care maternal and infant health services. It appears that there is some
uncertainty about the level of vaccination coverage for Indigenous children, with
some estimates being much lower than the general population to others indicating
that they are similar to other children. Indigenous children from remote areas tend to
have higher immunisation rates than those in urban areas.72
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In remote communities even a barely adequately resourced primary health care
service should have the capacity, access to children and record systems to support
the maintenance of high vaccination rates. The priority of this activity is self evident to
professionals in such services. In urban settings, primary health care services may
have a higher proportion of occasional clients and not have a clear picture of a child
or families ongoing care requirements. It is possible that the lower immunisation rates
reported in some urban Indigenous populations also represents a paradoxical lack of
actual service access or health seeking behaviour on the part of Aboriginal and
Torres Strait Islander families. This is clearly a priority for all urban primary health
care providers with Indigenous clientele and requires cooperation between those
service providers.
Home visiting programs Finally in this section we examine the potential of primary health care staff visiting
pregnant women and young families at home as a key intervention both to improve
the health of mothers and children and a number of other long term outcomes for
children.
There have been models of health staff visiting the home of mothers with young
children for decades and there are many such models from which to choose. Recent
interest has been captured in Australia by the work of David Olds and his colleagues
in the USA, with the Australian Government allocating $40 million to a rigorous pilot
of a similar model in seven rural and remote Indigenous communities.
The importance of Olds’ studies73 is that they are based on a detailed, structured and
documented model, clarity about workforce requirements and training, and a rigorous
approach to evaluation. The model has Randomised Control Trial results in three
different United States jurisdictions. They show that, provided the model is followed
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73
Olds D L, Eckenrode J, Henderson C R, Kitzman H, Powers J, Cole R, Sidora K, Morris P, Pettitt L M, Luckey D
(1997) ‘Long-term effects of home visitation on maternal life course and child abuse and neglect: fifteen-year followup of a randomized trial’ JAMA 278:637-43; Olds D, Henderson C R, Cole R, Eckenrode J, Kitzman H, Luckey D,
Sidora K, Morris P & Powers J (1998) ‘Long-term effects of nurse home visitation on children's criminal and antisocial
behavior: fifteen-year follow-up of a randomized controlled trial’ JAMA 280:1238-1244; and especially Olds D L,
Henderson C R, Kitzman H J, Eckenrode J J, Cole R E and Tatelbaum R C (1999) ‘Prenatal and Infancy Home
Visitation by Nurses: Recent Findings’ The Future of Children Home Visiting: Recent Program Evaluations 9(1):4465.
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and for the populations he has studied, there are positive results in a number of key
outcome measures.
Positive outcome measures included a number of health measures – such as
increased birth weights of babies born to young and smoking mothers, reduced
attendances in Emergency Departments as a result of safer home environments,
smoking rates among mothers and greater father involvement, eg in birthing classes.
As well there was a trend to higher developmental scores at 6, 12 and 24 months
and babies in the interventions group cried less, were less likely to be punished and
were exposed to a greater number of appropriate play materials. There was no
impact on education outcomes at age 4, nor was there a reduction in incidence child
abuse, although there was a reduction in severity. Mothers in the control group were
also found to be less at risk of rapid successive pregnancies, which are a major
impediment for women to successfully complete education and/or get jobs, with
consequent long-term effects on themselves and their children74.
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Olds also notes, however, that when he substituted paraprofessionals for nurses the
gains fell away, as it did when other essential program elements were modified.
There is a general lesson, that taking the “idea” of an intervention is not as effective
as implementing that idea in a disciplined way. It is also likely that, in common with
many other interventions, the presence of severe violence or significant illicit drug
use in a home makes home visiting much less likely to succeed.
The importance of this body of work for the development of family-centred primary
health care is that it points to the importance of design integrity and not watering
down interventions for disadvantaged populations; that sustained home visiting has
been shown to produce a number of very important outcomes (though not as a
panacea) in areas that are both important and difficult for service providers; and that
it offers a well documented, indeed manualised, intervention.
Models in Aboriginal and Torres Strait Islander maternal and child health In this section we examine a number of successful models of primary health care
innovation to improve the effectiveness of maternal and child health services in
Aboriginal and Torres Strait Islander communities. There are a limited number of
published evaluations on successful interventions in the field of Aboriginal and Torres
Strait Islander maternal and child health. The following is a sample of some of the
74
Olds et al 1999 op cit. p 47
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key programs cited in the literature.75 We have selected these particular service for
variety in governance structure, program and location, and because they illustrate
some of the varied paths to success.
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We follow the case studies with a list of some of the key factors for success.
Mums and Babies Program – Townsville Aboriginal and Islander Health Service 76
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Established in 2000 to address community concern regarding pregnancy, birth and
infancy outcomes in the Indigenous community in Townsville, this multidisciplinary
team provides comprehensive antenatal care, postnatal care, immunisations, growth
monitoring, developmental screening and hearing screening for pregnant women,
families, infants and young children.77
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While run from an Aboriginal community-controlled health service, the Program has
close working links with a number of Queensland Government programs, as well as
Centrelink, James Cook University, and the Townsville Division of General Practice.
An evaluation of this program indicated a large increase in services provided and
evidence of some reductions in both low birth weight and perinatal death.78
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Congress Alukura Alukura was developed by Central Australian Aboriginal Congress in Alice Springs
during the mid-1980s as a women’s health and birthing centre for the Aboriginal
women of Central Australia. It is an important centre for the delivery of maternity and
women’s health services for women (particularly those from Alice Springs), providing
home visiting, transport, specialist / hospital liaison, a limited mobile bush service and
health education. It is staffed by a multidisciplinary team including a doctor,
midwives, Aboriginal Health Workers, nurses, a liaison officer, health educators, with
the assistance of traditional Grandmothers.
From the period 1986-1990 to the period 1996-99, the average birth weight of
Aboriginal infants in the Alice Springs urban area increased from 3,168g to 3,268g,
an increase of 100g.79
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75
For a more complete list, see Eades 2004 op cit and Herceg A (2005) Improving Health in Aboriginal and Torres
Strait Islander Mothers, Babies and Young Children: A Literature Review, Office for Aboriginal and Torres Strait
Islander Health
76
We understand that in recent times this program has essentially ceased, with some key staff leaving the Townsville
Aboriginal and Islander Health Service. Undoubtedly, the reasons for this are complex and will be the subject of
further investigation.
77
Panaretto K (2003) Mums and Babies Project: Project Report. Townsville, Townsville Aboriginal and Islanders
Health Service Limited.
78
Atkinson R (2001) Antenatal care and perinatal health – how to do it better in an urban Indigenous community.
th
Proceedings of the 6 National Rural Health Conference, Canberra.
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NSW Aboriginal Maternal and Infant Health Strategy The New South Wales Aboriginal Maternal and Infant Health Strategy began in 2001
with an overall goal of improving the health of Aboriginal women during pregnancy
and decreasing perinatal morbidity and mortality.
The strategy included targeted antenatal / postnatal programs for Aboriginal women
and infants; a state-wide training and support program for midwives and Aboriginal
health workers who provided these services; and an evaluation of the pilot program.
In five of the six former Area Health Services where the strategy was implemented, a
community midwife and Aboriginal health worker team were established to provide
community based services for Aboriginal women in conjunction with existing medical,
midwifery, paediatric and child and family health staff. The sixth region commenced
their program later in response to identified community need.
The final evaluation showed that services across the program were provided to 321
women in 2003 and 368 women in 2004. A number of results were documented80:
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births to women aged less than 20 years decreased from 24% in 1996-2000 to
21% in 2003;
•
the proportion of women attending for their first antenatal care visit before 20
weeks gestation increased significantly from 65% in 1996-2000 to 76% in 2003;
•
the proportion of women who reported smoking in the second half of their
pregnancy decreased from 59% in 1996-2000 to 55% in 2003;
•
the proportion of women who gave birth to preterm or low birth weight babies was
unchanged for women in the program in 2003 compared to 1996-2000; and
•
the perinatal mortality rate decreased from 20.4 per 1000 live births in 1996-2000
down to 9.4 per 1000 live births in 2003, although this finding was not statistically
significant.
Strong Mothers, Strong Babies, Strong Culture The Northern Territory Government’s Strong Women, Strong Babies, Strong Culture
(SWSBSC) program began in 1993 with the aim of increasing infant birth weights by
earlier attendance for antenatal care and improved maternal weight.81
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79
Ah Chee D, Alley S, Milera S (2001) Congress Alukura – women’s business. Proceedings of the 4th Australian
Women’s Health Conference, Adelaide, 19-21 February 2001.
80
NSW Health (2005) NSW Aboriginal Maternal and Infant Health Strategy Evaluation. Available:
http://www.health.nsw.gov.au/pubs/2006/evaluation_maternal.html
81
Mackerras 2001 op cit.
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Amongst other results, evaluation has shown twice the increase in birth weight in the
three pilot communities compared to non-participating communities (171g compared
to 92g). There was also an increase in the proportion of women attending their first
antenatal visit in the first trimester of pregnancy.
Nganampa Health Council Over many years, Nganampa have run an antenatal program in the Anangu
Pitjantjatjara lands of South Australia, also reaching women travelling from
neighbouring communities in the Northern Territory and Western Australia. The
program aimed to encourage early provision of antenatal care and at least five
antenatal care visits for each pregnancy.
An independent review82 of the period between 1984 and 1996 found that perinatal
mortality rates had decreased dramatically (from 45.2/1000 to 8.6/1000) and that the
proportion of babies born of low birth weight decreased from 14.2% to 8.1%. Average
birth weight also increased.
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Daruk Health Service Western Sydney’s Daruk Health Service has an antenatal clinic which provides home
visits, transport to clinics, ultrasound screening, support in labour and postnatal
care.83 Since beginning, the program has seen an increase in the number of
antenatal visits by local Aboriginal women, as well as a higher proportion presenting
earlier in their pregnancy.
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Principles for success One of the lessons from the delivery of primary health care services to Indigenous
communities in Australia is that what the evidence tells us and what local
communities are capable of and want to do, are both important in creating successful
programs. If Aboriginal community engagement in the delivery of health services is
crucial to their success, equally important is the involvement of policy makers,
researchers and health professionals – in short, those who can advise and work with
the community of some of the key interventions described above.
Many of the programs described in the literature are multifaceted as well as being
delivered alongside other programs from both within and outside the primary health
care service. Under these conditions it is vain to try to identify a single part of the
program that delivers success – or even sometimes, to isolate what part the whole
program plays in population level health changes.
82
Sloman D, Shelly J, Watson L, & Lumley J (1999) Obstetric and Child Health Outcomes on the Anangu
Pitjantjatjara Lands, 1984–1996: A preliminary analysis. 5th National Rural Health Conference, Adelaide.
83
DOHA (Department of Health and Aged Care) (2001) Better Health Care: Studies in the successful delivery of
primary health care services for Aboriginal and Torres Strait Islander Australians. Department of Health and Aged
Care, Canberra.
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Despite this, we identify eight key principles for success exemplified by the above
programs as follows:
1. Local community engagement with the program, including employment of
local Aboriginal people as key service deliverers and planners;
2. A named commitment to a focus on child and maternal health, where efforts
are backed from the governance level of the service;
3. A professional multidisciplinary workforce dedicated to the program and
supported with the relevant training;
4. Properly resourced, including over time to enable a sustained effort;
5. Good clinical and management systems;
6. Collaboration with other local services (hospitals, Government/nonGovernment health services, other primary health care services)
7. Easily accessible, either through the provision of transport or through
outreach and/or home-visiting programs;
8. A space or location set aside for the service and specifically safe for women
and children.
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CHAPTER SUMMARY: MATERNAL AND CHILD HEALTH
1. Maternal and child health services are ‘core business’ for the primary health
care sector. Their accessibility, appropriateness and effectiveness are central to the
concept of family-centred primary health care.
2. Key areas for primary health care intervention include:
a) Predominantly focused on women before and during pregnancy:
•
Tobacco
•
Alcohol
•
Sexual health
•
Antenatal care
•
Family planning
•
Nutrition and folate
•
Social support and education
b) Predominantly focused on the child after birth:
•
Breastfeeding
•
Nutrition
•
Immunisation
c) Home visiting:
There is strong evidence from overseas that nursing staff visiting pregnant women
and young families at home can deliver positive results in the health and
development of children. However, design integrity and sustained programs are
critical for success.
3. Principles for successful primary health care interventions, include:
•
Local community engagement, including employment of local Aboriginal people
•
A commitment to a focus on child and maternal health;
•
A professional multidisciplinary workforce supported with training;
•
Proper resourcing to enable sustained effort;
•
Good clinical and management systems;
•
Collaboration with other local services;
•
Accessibility (provision of transport / outreach / home-visiting programs);
•
A space that is safe (and if possible, separate) for women and children.
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3.
Education and Health We have seen in the previous section how the health of a mother during pregnancy,
and the experience of the infant in utero and through the first years of life can have
far-reaching consequences for health over the life course. The first few years of life
set children on life trajectories that become progressively more difficult to remedy as
social disparities widen and associated cultural reinforcements kick in.84
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We have also seen that, from a child development perspective, health, education and
welfare thinking may be focused through different disciplinary lenses but are all
essentially about the same set of issues in the early years.
Accordingly, a key site for intervention is the education sector, with a voluminous
literature showing a strong link between educational attainment and health in later
life.
Unlike child and maternal health services, interventions to address early educational
deficits or to continue a positive educational start to build a healthy platform for life,
fall outside even a comprehensive model of primary health. However, the question
that needs to be asked is: how can the primary health care sector contribute to the
greater effectiveness of the education sector – how can it complete the circuit?
In this chapter we will look first at the evidence on the relationship between education
outcomes and health outcomes, then following the same path as Chapter Two we will
examine the education outcomes for Australian Indigenous children, and examine
key intervention points linking health and education, especially at the challenges that
this raises for primary health care practice.
A Summary of the Evidence The relationship between health and education There is strong evidence linking early childhood development to literacy, social
competence and success in school, and in turn, that education attainment is linked to
personal health status and socio-economic position later in life.
Put at its simplest, those with poor social and health environments at the beginning of
their lives are likely to have poor education outcomes, and then poorer health
outcomes later in their lives, whether measured by health knowledge, intermediate
84
Shonkoff and Phillips 2000 op cit.
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disease markers, measures of morbidity, general health status, and use of health
resources.85 Similarly, improved education can independently override these effects.
Writing in this field began in the 1970s with work on the social determinants of health
and developing country transitions demonstrating the impact of socio-economic
disadvantage at a community and neighbourhood level in terms of poorer health
outcomes86. Educational attainment consistently ranked as a key indicator and
mediator of such disadvantage. Since then, an extensive literature has developed
that demonstrates the links between child development, education and health along
the life course: at an individual level, at the level of the family, and of the community.
Children who can read and write and numerically calculate are most likely to be longlived, healthy, and have a positive place in society.87 On the other hand, children that
are brought up experiencing disadvantaged, neglectful or abusive early childhood
development conditions may show antisocial behaviour by the time they enter the
school system, and have reduced performance throughout their school years88.
Further literature indicates an association between IQ in childhood, and health later
in life.89
There are a number of interconnected pathways by which this effect may be
expressed.
First is the importance of work and class, or socioeconomic status. Education is the
key to one’s place in a stratified economy90 where educated children are more likely
to grow up into adults with better socioeconomic status which is strongly associated
with better health, a greater ability effectively to access health services and lower
mortality.91
Second, education is associated with better social-psychological resources:
stressors, hardships, beliefs and behaviours are not randomly distributed but are
socially structured. The sense of control over one’s own life increases with education,
85
Dewalt D A and Berkman N D (2004) ‘Literacy and health outcomes: a systematic review of the literature’ Journal
of General Internal Medicine 19.
86
Caldwell J C (1986) ‘Routes to Low Mortality in Poor Countries’ Population and Development Review 12:171-220;
Flegg A T (1982) ‘Inequality of Income, Illiteracy and Medical-Care as Determinants of Infant-Mortality in
Underdeveloped-Countries’ Population Studies 36:441-458; Rogers R G and Wofford S (1989) ‘Life Expectancy in
Less Developed-Countries – Socioeconomic Development or Public Health’ Journal of Biosocial Science 21:245-252.
87
Mustard 2006 op cit.
88
Tremblay R E (1999) ‘When children’s social development fails’ In Keating D & Hertzman C (Eds.) Developmental
health and the wealth of nations: Social, biological, and educational dynamics (pp. 55-71). New York. Guilford.
89
Chandola T, Deary I J, Blane D and Batty G D (2006b) ‘Childhood IQ in relation to obesity and weight gain in adult
life: the National Child Development (1958) Study’ International Journal of Obesity 30:1422-1432; Hart C L, Taylor M
D, Smith G D, Whalley L J, Starr J M, Hole D J, Wilson V and Deary I J (2004) ‘Childhood IQ and cardiovascular
disease in adulthood: prospective observational study linking the Scottish Mental Survey 1932 and the Midspan
studies’ Social Science and Medicine 59:2131-8.
90
Ross C E and Wu C (1995) ‘The Links Between Education and Health’ American Sociological Review 60 (5):719745)
91
Hertzman and Wiens 1996 op cit.
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employment and income.92 Some Australian literature points to pathways between
educational attainment and impact on the social and emotional well-being of
Indigenous peoples.93
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Third are some of the practical skills that come with better education, allowing
individuals to be better able to manage their health (e.g. to access services,
comprehend health messages, and advocate on their own behalf).94 Many ‘lifestyle
factors’ such as eating well, drinking moderately, not smoking and preventive health
care are strongly associated with better education.95 These ‘individual choice’
capacities are enabled by affluence and means, to which education once again
contributes.
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Fourth there is considerable international literature connecting the educational
attainment of parents, in particular the mother, and child health outcomes. In
developing countries a clear relationship is found between education of the mother
and reduced infant child mortality, which is thought to be related to the greater
autonomy and control of women over their lives and the lives of their children.96 In
addition, poor maternal education in industrialised countries leads to increased risk of
developmental delay for their children.97
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The Australian Indigenous context A note on the evidence As with other fields noted in this report, there is a general paucity of evidence for
‘what works’ in the Indigenous domain, compounded by an overall lack of solid
research and quality evaluation into/of early childhood, parent support and family
interventions in Australia.98 Much valuable work remains in the heads of people as
practice based wisdom and is not written up.
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The majority of efficacy studies come from the United States, as a result of their
heavy investment in early intervention programs and theorising in the 1960s and
92
Ross and Wu 1995 op cit; Marmot and Wilkinson 1998 op cit.
93
Corrigan M and Mellor S (2004) The Case for Change: A Review of Contemporary Research on Indigenous
Education Outcomes. Australian Council on Educational Research; Hunter B H and Schwab R G (2003) Practical
reconciliation and recent trends in Indigenous education. Centre for Aboriginal Economic Policy Research. Available:
http://hdl.handle.net/1885/41585.
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94
Berkman N D, DeWalt D A, Pignone M P et al (2004) Literacy And Health Outcomes Evidence report/technology
assessment Number 87 prepared for Agency for Healthcare Research and Quality (AHRQ) US Dept Health and
Human Services)
95
Ross C E and Wu C L (1996) ‘Education, age, and the cumulative advantage in health’ J Health Soc Behav
37:104-20
96
Caldwell 1986 op cit; Caldwell 1990 op cit; Sandiford P, Cassel J, Montenegro M and Sanchez G (1995) ‘The
Impact of Women's Literacy on Child Health and its Interaction with Access to Health Services’ Population Studies
49(1):5-17.
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97
Shonkoff & Phillips 2000 op cit.
98
Herceg 2005 op cit
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1970s, and equally heavy input of foundations in evaluative research and longitudinal
trials.
Australia does not have this legacy to draw upon, and the applicability of these
overseas interventions to the Australian – and particular the Australian Indigenous –
context is a matter of some debate. On the one hand there are those who would
argue that only local, grassroots solutions that are developed through appropriately
paced action research methods will have a chance of working. On the other, there
are arguments that ‘children are children’ wherever they are and the overseas
evidence is applicable universally.
These two points of view need not be mutually exclusive. In fact we believe the
tension between the two can be used creatively with programs designed and
implemented locally, based on principles proven to work universally. Central to the
success of such an approach is the need for engagement with the community and its
capacities, coupled with the critical reflection and robust evaluation of programs.
The skills and capacities built up in the health research sector, applied to studies of
the link between health and educational outcomes is a productive area for further
work – indeed, the exchange of skills between health and education can operate not
just at the level of service development and implementation, but also at the level of
applied research as well.
Aboriginal education Measured by both participation and achievement, Indigenous children in Australia are
receiving poorer education than their non-Indigenous counterparts. The nationally
agreed literacy and numeracy benchmarks for Years 3, 5 and 7 represent minimum
standards of performance below which students will have difficulty progressing
satisfactorily at school. In 2001, the preschool participation rate for Indigenous
children was 46% compared with 57% by other Australian children, while later in
school, the proportions of Indigenous students meeting the national benchmarks for
reading and writing were consistently lower than those for other children.99
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From that point on in their life course, and at all levels of measurement, large gaps
remain between Indigenous and non-Indigenous students. The most recent National
Report to Parliament on Indigenous Education and Training (2006) confirms that
while there have been nation-wide improvements in measures of enrolment and
retention, overall, achievement gaps that appear in Grade Three tests widen as the
student ages. As Indigenous children grow older, the gap widens at a rate of about
nine months for every year at school.100
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99
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AIHW 2005 op cit pxiv
100
Commonwealth of Australia (2006) National Report to Parliament on Indigenous Education and Training, 2004
Australian Government Printer. Canberra. pp 40-45.
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The Western Australia Aboriginal Child Health Survey also reported poor educational
outcomes for Indigenous children. Approximately, 57% of Aboriginal children had low
academic performance compared with 19% of all children101.
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While the developmental education disparities are already evident when Indigenous
children enter school and widen from there in the absence of active intervention, the
number of Indigenous children accessing child care services remains lower than for
non-Indigenous children across Australia.102 In the Northern Territory, an estimated
2000 children who are eligible for preschool or early care and learning programs do
not currently access such a service.
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The links between education and health
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The recent publication Social determinants of Indigenous health103 summarised the
Australian literature on the link between educational attainment and health.
According to this study, the causal pathways underlying interactions between
Indigenous participation in mainstream education and health outcomes are complex.
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Confirming this, the international research identifies multiple pathways connecting
health and education, to the point where one researcher has said it is “one of most
powerful relationships in social science, yet it is perhaps the most difficult to
explain”.104
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The difficulty partly lies in the fact that the relationship is bidirectional: health status
impacts on the capacity to be educated and vice versa, although there is more
evidence that initially, better education lead to better health outcomes (and not
automatically the other way around).
Additionally, the relationship between education and health is neither static nor linear:
life course and cohort processes bear directly upon both domains.105 It is hard to
disentangle educational attainment from its links with income and class status. Yet
for all this, those with more education have better health for all levels of income, and
fewer income-based disparities exist among the well educated than among the less
well educated.
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101
Zubrick S R, Silburn S R, De Maio J A, Shepherd C, Griffin J A, Dalby R B, Mitrou F B, Lawrence D M, Hayward
C, Pearson G, Milroy H, Milroy J and Cox A (2006) The Western Australian Aboriginal Child Health Survey: Improving
the Educational Experiences of Aboriginal Children and Young People. Curtin University of Technology and Telethon
Institute for Child Health Research.
102
OECD (2006) Starting Strong II: Early Childhood Education and Care. Organisation for Economic Cooperation and
Development
103
Carson B, Dunbar T, Chenhall R D, and Bailie R (eds.) (2007) Social Determinants of Indigenous Health. Allen
and Unwin.
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104
Lynch S M (2003) ‘Cohort and life-course patterns in the relationship between education and health: A hierarchical
approach’ Demography 40:309-331 (p 309)
105
ibid; Ross and Wu 1996 op cit.
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While the evidence from elsewhere is clear on the existence of a fundamental
interconnection between health and education (if less clear on the key causal links),
there are no publications that clearly demonstrate for Indigenous people in Australia
that higher levels of education lead to better health. Similarly, there is limited
evidence available on the relationship between maternal education and child health
outcomes for Indigenous Australians, despite this being one of the longer standing
associations in the international epidemiological literature.106
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Intervention points for education and health In Chapter Two, regarding maternal and child health, we saw how appropriate care
for pregnant women and infants in their first years delivered from the primary health
care sector can play a role in building the long-term health of populations.
The evidence we have just outlined demonstrates education’s strong positive effect
on health throughout life and how, conversely, a poor start in education can become
another cumulative disadvantage for a child.
This is not about parents who are ‘failing’ – it is about addressing deficits in the
environment in which a child grows up.
While a number of the health conditions that interrupt learning are addressable within
comprehensive primary health care systems conventionally understood, the most
important interventions here are likely to be from outside the primary health care
sector, and in this section we will briefly outline some of the key interventions which
might assist early development and better education for Indigenous children, before
turning to the question: what can the primary health care sector – using a ‘familycentred’ approach – contribute? How can it intervene in such a way as to ensure that
Aboriginal and Torres Strait Islander children are getting the best education they can,
and setting themselves up for a longer, healthier life?
Key features of interventions to enhance education outcomes Early intervention / school readiness Early childhood intervention programs (EIPs) aim to provide some protection against
the various risk factors that can impact adversely on healthy child development in the
years before school entry.
The benefits of early intervention for children and their families are well documented.
While EIPs are highly varied in their objectives, their targets, and the age of child on
106
Boughton B (2000) What is the Connection Between Aboriginal Education and Aboriginal Health? CRC for
Aboriginal and Tropical Health Occasional Paper Series, Issue No 2 2000.; Caldwell J C 1986 op cit.
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which they focus, overall they have been shown to reduce disparities between
families107 and their benefits appear to be greatest in populations at “highest-risk”,
that is, those characterised by poverty, social isolation, cultural and linguistic
diversity, with poor health, educational and social outcomes.108
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Additionally, current evidence suggests that the greatest gains are achieved by
intervening early in the life course.109 Programs that intervene in the first six or eight
years of life are more successful at improving core developmental outcomes than
later interventions. Further, the evidence suggests that the ‘neural sculpting’ of the
child’s brain in the first three years is critical and that to have well-educated children it
is important not to leave the acquisition of language and familiarity with numbers until
the years of formal schooling. Of particular relevance to the Indigenous context, this
period is also critical for the acquisition of a second language. Unfortunately, it is also
one of the least well-resourced areas of Indigenous social service delivery.110
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Family support and parenting programs Relationships of a child to parents and other care-givers are critical to their healthy
development. Strong, caring relationships strengthen the child’s development and
while the mother-child relationship is usually the most important, in the Aboriginal
context in particular, a number of care-givers may be important to the child.
One approach ameliorating the risks faced by a disadvantaged child is to focus on
these care-givers with family support and parenting programs. This has been a focus
also in the education sector. The evidence is that localized and specific programs
focusing on the family and parenting can improve children’s early literacy skills.111
Again, these interventions are varied in scope, target, and objective, and once more
the literature is heavily weighted towards overseas examples.
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Structured playgroups and quality child care There is good evidence that, especially for disadvantaged children, access to
structured playgroups and quality child care services with an educational component
is advantageous in terms of educational achievement. This gain is, however,
dependent on the quality of the program and presence of trained staff, including in
child care, early childhood educators.112
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107
Karoly et al 1998 op cit.
108
Olds et al 1997 op cit; Olds et al 1998 op cit.
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109
Carneiro P & Heckman P J (2003) Human Capital Policy. Discussion Paper No.821. The Institute for the Study of
Labour (IZA). Bonn. Germany. Available: http://ideas.repec.org/p/iza/izadps/dp821.html
110
A point made in Anderson P and Wild R (2007) Little Children are Sacred: Report of the Northern Territory Board
of Inquiry into the Protection of Aboriginal Children from Sexual Abuse. Northern Territory Government. Darwin.
111
Shonkoff and Phillips 2000 op cit
112
Mustard 2006 op cit; Mustard 2006 op cit; Low et al 2005 op cit; Karoly L, Kilburn R, Cannon J (2005) Early
Childhood Interventions: proven Results, Future Promise. RAND Corporation Report (www.rand.org)
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There is some debate about whether programs targeted at children/families at risk
are the best approach compared to universal, population based programs. This often
arises in relation to the importance of access to quality child care. One argument is
that universal quality child care benefits all children so a population approach will
benefit a greater number of at risk children wherever they are located, as well as
securing broad societal support.113 Others argue for targeted programs as a way of
addressing social and economic disparities in society114, and overcoming the skewed
manner of social service provision, with educated and well-off families getting better
access to and better quality versions of whatever ‘universal’ programs are on offer.
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We would argue that both universal and targeted programs are needed: while some
interventions for at risk families and children can have impressive results, the
outcomes do not nearly match those of advantaged children who had greater
opportunities from the outset115 – and consequently there remains a key political task
‘upstream’ in terms of minimising the social and economic disadvantage of families in
the first place.
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Key factors for success Much literature has focused on what family or early childhood interventions are most
likely to lead to improved child development and educational attainment. Overall
there seem to be some key features of successful programs:
1. Parental involvement – social interventions in the child care arena have
greatest chance of beneficial outcomes if they reach the child through the
parent. Accordingly, childhood development programs should encourage their
voluntary participation, so that parents can simultaneously learn parenting
techniques116;
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2. Content matters – successful programs are not simply a matter of providing
good community day care but have a focus on developmental goals117 and
attention to the development of cognitive skills including the development of
letter and number recognition, pre-reading and language skills118; Programs
need to be outcome orientated according to the three key domains of early
child development: physical, cognitive and socio-emotional-behavioural;
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113
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McCain and Mustard 1999 op cit
114
Low M D, Low B J, Baumler E R and Huynh P T (2005) ‘Can education policy be health policy? Implications of
research on the social determinants of health’ Journal of Health Politics Policy and Law 30:1131-1162.
115
Hertzman C and Wiens 1996 op cit
116
Mustard 2006 op cit.
117
ibid
118
Low et al 2005 op cit
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3. Staffing – programs have well-trained staff (preferably four-year trained)119
with low client to staff ratios120;
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4. Be home or centre-based – both can work (including home visiting121)
depending on frequent contact with program staff122;
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5. Local and specific – especially for high-risk families facing multiple problems,
general parenting and family support programs that are overly general seem
to yield little benefit123. Halpern in particular issues some caution regarding
so-called comprehensive programming, which often relies on a “vague”
system of referral and case management across organizations.124
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Opportunities for a direct primary health care contribution Given this evidence of the link between health and education and the key
interventions in this field, what role can primary health care services play to support
children and families to maximise educational outcomes?
As noted, a child's health is crucial to their participation and success at school.
Primary health care programs to ensure that children are healthy and ready to learn
while at school are best seen as working integrally with family support programs such
as those described above.
Nutrition As well as having long-term health implications for healthy development, poor
nutrition of infants and preschool children has been shown to affect cognitive function
and this can last into the school years125, being specifically associated with delayed
motor development, impaired cognition, and poor school performance. Iron
deficiency has also been associated with poor cognitive function and delay in
psychomotor development, in preschool and young school-age children.126 Anaemia
has been found to be very prevalent in some Aboriginal communities, with rates
recorded as high as 39% found in some remote communities.127 Iodine deficiency in
school children has also been associated with impaired cognitive ability and poor
school performance.
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119
Mustard 2006 op cit; Low et al 2005 op cit; Karoly L, et al 2005 op cit
120
Karoly et al 2005 op cit
121
Hertzman and Wiens 1996 op cit.
122
Karoly et al 2005 op cit
123
Shonkoff and Phillips 2000 op cit.
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124
Halpern, R. (2000) Early childhood intervention for low-income children and families, New York, Cambridge
University Press p 377
125
World Health Organisation (WHO) and World Bank (2002) Better Health for poor children. A special report.
Available: http://www.who.int/child-adolescent-health/publications/CHILD_HEALTH/WHO_FCH_CAH_02.5.htm
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126
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ibid
127
Paterson B, Ruben A, Nossar V (1998) ‘School screening in remote Aboriginal communities – results of an
evaluation’ ANZ Journal of Public Health 22(6):685-9
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Nutrition and health promotion services have been integrated into family support
programs for Indigenous families both here in Australia (the Best Start program in
Victoria and Western Australia)128 and overseas (the Aboriginal Head Start program
in Canada). The Victorian Department of Health Services ‘2004 Aboriginal Best Start:
Status Report’ does not provide a timeline for implementation of the Aboriginal Best
Start Demonstration Phases, which were underway when the 2004 report went to
print. (Unfortunately, the review team were unable to locate evidence of outcomes of
the demonstration phase in either published or unpublished form).
In Australia, community based nutrition counseling interventions integrated into
primary health care services have been found to have modest benefits in promoting
growth amongst children.129 School-based nutrition programs to improve school
performance and attendance can distribute healthy meals to students at school as
well convey health and nutrition information to the students and their families. The
National Aboriginal Community Controlled Health Organisation has called for food
supplementation programs to be used as an incentive to school attendance
combined with targeted nutritional programs for Aboriginal women in high risk
groups.130
A recent review commissioned by OATSIH on effective interventions to improve the
social and environmental factors impacting on health noted at the time that there
were no nationwide supplementary feeding programs in Australia.131 National
programs are of course unusual in school education which is a program area
administered by the states and territories. However, since that report went to print,
the Australian Government has introduced breakfast programs as part of the suite of
emergency measures being introduced in targeted communities in the Northern
Territory.
The effect of such programs on improved cognition and ability to learn, as opposed to
weight gain and such measures as temporarily improved attendance, is unclear. An
earlier paper evaluating preschool supplementary meal programs on the nutritional
health of Aboriginal children in five New South Wales rural towns used
anthropometric measurement and pathology testing. The outcomes were increased
128
Note that the Commonwealth Department of Education Science and Training’s ‘Parent School Partnership
Initiatives’ also supports some nutrition projects where the project can be shown to have an effect on school
attendance and educational outcomes, particularly literacy and numeracy skills. However, the review team have not
been able to source evaluations of such projects.
129
McDonald E, Bailie R, Morris P, Rumbold A & Paterson B (2006) Interventions to Prevent Growth Faltering in
Remote Indigenous Communities, Australian Primary Health Care Research Institute, Australian National University,
Canberra.
130
NACCHO 2003 What’s needed to improve child health in the Aboriginal and Torres Strait Islander Population.
Available: http://www.naccho.org.au/PolicyReports/Reports/ChildHealth.html
131
Black A (2007) Evidence of effective interventions to improve the social and environmental factors impacting on
health : informing the development of Indigenous Community Agreements. Department of Health and Ageing.
Canberra. Available: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-oatsih-pubs
-evidence/$FILE/S&E%20Report.pdf
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weight and height, but decreased haemoglobin, vitamin C and ferratin.132 An
evaluation of nine projects targeting Indigenous school-age students (ages five to
nine) was able to find increased access to nutritious food, attendance and attention in
school.133
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Nevertheless, no intervention based on educating disadvantaged families about good
nutrition can have a sustained effect where access to nutritious food is non-existent,
limited, or expensive. Accordingly, in the Australian Indigenous context – particularly
in remote areas – a key primary health care intervention should be to ensure that
stores consistently carry nutritious foods priced such that community members can
afford to buy them.
Hearing health Indigenous children are much more likely than their non-Indigenous peers to have
ear disease and hearing problems. Middle ear infections (otitis media) are common,
particularly in remote area where the prevalence of otitis media ranges from 40% to
70% compared with only 5% in more advantaged populations internationally.134
Rates of otitis media in Western Australian Aboriginal children aged 5-9 months has
been found to be as high as 72%.135
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Hearing loss resulting from middle ear infections is associated with poor school
achievement: children who are unable to hear properly are at an obvious
disadvantage in the classroom, particularly in acquiring language and reading skills.
The problems are exacerbated by the fact that for many, English is not the vernacular
or domestic language. Some evidence also suggests that Indigenous children with
chronic middle ear disease attend school less frequently than other children.136
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Primary health care services can contribute in a number of key areas:
•
infant ear health monitoring and focused treatment before school age;
•
school-based ear examinations and regular health screenings in schools;
•
involvement in ensuring that classrooms are designed, constructed and set
up to maximise auditory benefit for students.
132
Coyne T, Dowling M and Condon-Paoloni D (1980) ‘Evaluation of preschool meals programmes on the nutritional
health of Aboriginal children’ MJA 2:369-375.
133
Miller M, Coffin J, Shaw P, D'Antoine H, Larson A and James R (2004) Evaluation of Indigenous nutrition projects
funded by the National Childhood Nutrition Program in Western Australia. Perth. Telethon Institute for Child Health
Research, and Combined Universities Centre for Rural Health.
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134
ABS and AIHW 2005 op cit.
135
Zubrick et al 2004 op cit.
136
ABS and AIHW 2005 op cit.
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Developmental Screening A program addressing the needs of children at risk of poor development and
educational outcomes needs some way to ‘target’ those children and families.
Primary health care services can play a key role in identifying developmental and
health problems as they are likely to be a significant point of contact for young
children and their families in the early years of a child’s life.
The key principles for such screening have been identified as it being voluntary,
culturally safe, carried out by trained staff, confidential, and importantly, directed
towards identifying children and families who need further assessment, rather than
providing a diagnosis.137 Accessible and effective follow up services that are
sustainable and well coordinated with screening are also obviously important to the
appropriateness of screening strategies.
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Primary health care services can contribute in a number of key areas:
•
Identification of clinically significant health, emotional or behavioural problems
known to contribute to later conduct, learning and peer problems;
•
Coordination of professional support for pre-school and early childhood
teachers to enable at-risk students to access screening and the follow up
clinical interventions for medical conditions; and
•
Engagement of speech pathology and developmental specialists to ensure
children with identified speech and language problems arising from hearing
and other disorders have access to language enrichment programs.
Primary health care as a site for early learning interventions A further question that the above evidence on the importance of early learning
opportunity also raises is whether, as well as ensuring the effectiveness of core
health service interventions, primary health care sites could also provide direct
access on site to structured developmental programs targeting young children and
their carers? A number of international models to which we now turn lend weight to
the importance of this question.
Models for Intervention Benchmark programs that stand out in the literature on early intervention approaches
include the Nurse Home Visiting Program (NVHP)—also known as the Elmira
137
Rosman A, Perry D, Hepburn, K (2005) The best beginning: partnerships between PHC and mental health and
substance abuse services for young children and their families. US Department of Health and Human Services.
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Parent/Early Infancy Project138; the High/Scope Perry Preschool Program; and Early
Head Start. There are fewer Australian examples to draw upon which have used
experimental designs to determine their effectiveness or published their findings
outside internal reports, especially in relation to programs aimed at transition to
school. Unfortunately, neither Australian nor Canadian indigenous (Best/Head Start)
programs have reported findings. The United States based indigenous Head Start
Programs are more rigorous, although this once again throws up the question of
transferability.139
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It should be noted that the Nurse Family Partnership Program was reported under
the previous chapter on maternal and child health as it is an intervention which
targets first time mothers, from within a predominately maternal health perspective.
Models from overseas Head Start – United States Beginning in the US in 1965, this early childhood intervention program still exists
today with over 1300 Head Start centres located across the country providing
services to over 700,000 children.
The program is designed to promote healthy development in low-income children
from the ages of three to five, with a range of individualized services provided from
Head Start preschool centres in the areas of education and early childhood
development; medical, dental, and mental health; nutrition; and parent involvement.
There have been a number of evaluations which have demonstrated that children
who received early childhood intervention from the Head Start program were less
likely to spend time in special education programs; more likely to graduate from high
school; less likely to be teen mothers; five times less likely to be arrested repeatedly;
three times more likely to be home owners.
Aboriginal Head Start – Canada 140
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Established in 1995, the Aboriginal Head Start program aims to enhance healthy
child development and school readiness of Indian, Metis and Inuit children living in
urban centres and northern communities. The program had its origins in the US Head
Start programs, but was adapted to an Indigenous context.
138
Olds et al 1997 op cit; Olds et al 1998 op cit.
139
Marks E L, Moyer M K, Roche M R and Graham E T (2003) A summary of research and publications on Early
Childhood for American Indians and Alaska Native Children United States Department of Health and Human
Services; Marks E L and Graham E T (2004) Establishing a research agenda for American Indians and Alaska Native
Head Start Programs United States Department of Health and Human Services
140
Budgell, R (2002) Aboriginal Head Start Biennial Report 1998/1999 - 1999/2000. Available:
www.hc-sc.gc.ca/dca-dea/publications/biennial_e.html
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The primary goal of the initiative is to demonstrate that locally controlled and
designed early intervention strategies can provide Aboriginal children with a positive
sense of themselves, a desire for learning, and opportunities to develop fully as
successful young people. There are 126 Aboriginal Head Start (AHS) sites in
communities across Canada. Principles of local control and design are critical to the
program which is organized around six components: culture and language,
education, health promotion, nutrition, social support, and parental involvement.
Health Canada runs the program and partners with not-for-profit providers to deliver
a general half-day program operated five days per week. There is no standard
curriculum and the evaluation strategies in place are process oriented rather than on
the child’s trajectory once they leave the program.
Local project evaluations and ad hoc community reporting claim gains in all areas of
children's development and improved parenting skills in parents. A National Process
and Administrative Evaluation Survey is conducted annually which collects data
regarding AHS's team characteristics, project administration and co-ordination,
program participants and their communities, the delivery of and strategies and plans
associated with program components, program needs and program finances.
A National Impact Evaluation is in progress with the aim of demonstrating the impact
that AHS is having on the children families and communities participating in AHS.141
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Perry Preschool ‐ United States The Perry Preschool Study is among the more famous interventions, mostly for its
experimental research evaluation (involving randomised control comparisons) and
longitudinal follow up on the impact of the program on participants (annually from age
3 to 11 years, and then at ages 14, 15, 19, 27 and most recently 40 years).
Perry Preschool combines child development and school readiness programs within
the one intervention, targeting children from low-income families who were originally
assessed as being at high risk of school failure. There are notable differences in life
outcomes between the two groups.
As Zubrick et al142 summarise it, those who received the intervention did significantly
better on IQ tests at age 5 years, outperformed non-program children on intellectual
and language tests from pre-school through to age 7 years, did better on school
achievement tests from age 9–14 years and did better on literacy tests at age 19 and
27 years. As adults those who received the intervention did better economically with
better employment, higher earnings, higher levels of home ownership and less use of
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See http://www.phac-aspc.gc.ca/dca-dea/programs-mes/ahs_overview_e.html
142
Zubrick et al 2006 p475; see also Schweinhart L J (2006) The High/Scope Perry preschool study through age 40:
summary, conclusions and frequently asked questions. High/Scope Educational Research Foundation.
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social services. By the age of 40 years, the group who received the intervention had
sustained fewer lifetime arrests and had served significantly less time in prison.
Australian Models Best Start ‐ Western Australia and Victoria An Aboriginal Best Start program has been implemented in both Victoria and
Western Australia. The ‘DHS 2004 Aboriginal Best Start: Status Report’143 describes
the programs as follows:
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The Best Start program in Western Australia was first initiated in 1993 and is
a joint project between the Department for Community Development, the
Department of Health and the Education Department in Western Australia.
The program focuses on Aboriginal children from birth to five years of age,
with the aim of improving their wellbeing and life opportunities and preparing
them adequately for preschool and the first year of schooling by improving
their participation in early childhood education programs. In 1994, on the
basis of level of disadvantage and remoteness, six locations were identified
as fulfilling the criteria for the Best Start program, and, following consultation,
seven communities at these six locations were selected to pilot the program.
In subsequent years, other communities became part of the pilot program and
in 1996–97 there were 16 sites in operation. All Best Start programs are
owned and managed at the local Aboriginal community level.
A range of activities is offered through the program, including nutrition
programs for parents and carers, an immunization clinic, regular weekly
playgroups for young children, as well as cultural camps for children, parents
and other significant members of the extended family. In addition, drinking
fountains have been installed in communities to provide clean drinking water.
While several interim evaluations have been undertaken, the final evaluation
noted that the 15 sites operating between September 2000 and February
2001 had provided services to approximately 166 families, with playgroups
the most frequently used service. Problems related to the continuing ‘pilot’
status were noted and a recommendation made that this status should be
removed to overcome the insecurity it generates among staff, families and
communities. Other concerns centred on the adequacy of resources
available, the selection, training and support of suitable staff, problems
related to the provision of transport and the suitability of venues.
143
Gillam C (2000) Final evaluation of the Best Start pilot: report to the Interdepartmental Steering Committee,
Department of Family and Children’s Services, Perth.
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NT mobiles playgroups In 1997 the NT Education Department established a pilot program of visiting
playgroups in remote Aboriginal communities, encouraging the involvement of both
parents and children in a range of activities based on storytelling, art and craft and
also on introducing books and paper.
According to the Learning Lessons Report into Aboriginal Education in the NT,
children showed increased receptiveness to literacy and classroom activity at age 5
years.144
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Ngariprlinga’ajirri Early Intervention School Program, Tiwi Islands, NT Adapted from the Victorian Exploring Together program, this program targeted
children aged 6-12 years who had demonstrated behavioural problems including self
harming behaviour. It provided skills and strategies for parents as well as working
with the children. The program’s review reported teacher perceptions of significant
improvements in child behaviour, which were sustained at six months, a perception
shared by a similar proportion of children.145
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This program also demonstrated another common feature of such small scale but
successful programs, struggling for five years to secure stable funding, rather than
the short term pilot program grants that forced program managers and evaluators to
spend inordinate amounts of time attending to the business of securing funding,
rather than developing and fine-tuning the program.146
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144
NT Department of Education (1999), Learning Lessons: An independent review of Indigenous Education in the
NT, Darwin
145
Robinson G and Tyler B (2006) Ngaripirlina’ajirri: An early intervention program on the Tiwi Islands: final
evaluation report Charles Darwin University, Darwin
146
Robinson G, personal communication
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CHAPTER SUMMARY: HEALTH AND EDUCATION
1. Strong evidence links early childhood development to literacy, social
competence and success in school, and in turn to health status later in life.
2. There is an overall lack of solid research and quality evaluation in Australia on
early childhood, parent support and family interventions. However, international
evidence can provide insights to what can be expected in Australia.
3. Interventions predominantly from outside the primary health care sector
include:
•
school readiness programs, including pre-schools and day care programs with
structured pre-school educational curricula and structured playgroups
•
family support and parenting programs
•
early intervention programs that incorporate both elements
4. Direct primary health care interventions include in the areas of
•
nutrition
•
hearing health
•
developmental screening
•
primary health care services as a possible site for early learning interventions
5. Factors for success for these programs include
•
•
parental involvement
content that focuses on developmental needs and prepares children for school
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well-trained staff with low client to staff ratios
•
accessibility ( home or centre-based)
•
local and specific to the needs of the community
•
Primary health care programs that work integrally with interventions from outside
the PHC sector.
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