1. No category

Office for Aboriginal and
Torres Strait Islander Health
Department of Health and Ageing
FAMILY CENTRED
PRIMARY HEALTH CARE
THINK CHANGE
In association with JTAI Pty Ltd
Submitted by
Robert Griew, Director
Robert Griew Pty Ltd, trading as
Robert Griew Consulting
PO Box 433, Waverley NSW 2024
The Charing Cross Centre
199 Bronte Road, Waverley NSW 2024
T: 02 9389 1779
F: 02 9389 3779
E: [email protected]
I am not yet born; provide me
With water to dandle me, grass to grow for me, trees to talk
to me, sky to sing to me, birds and a white light
in the back of my mind to guide me.
From Prayer before Birth
by Louis MacNeice
FAMILY CENTRED
PRIMARY HEALTH CARE
Review of evidence and models funded by the
Office for Aboriginal and Torres Strait Islander Health
Department of Health and Ageing, Canberra
Robert Griew Consulting
Associate Professor Robert Griew
Mr Edward Tilton
Ms Jess Stewart
With
Professor Sandra Eades
Associate Professor Tess Lea
Ms Carol Peltola
And
JTAI Pty Ltd
Ms Louise Livingstone
Ms Karen Harmon
Ms Zoe Dawkins
November 2007
This paper has been funded by the Office for Aboriginal and Torres Strait Islander
Health, Department of Health and Ageing. The views in the paper do not
necessarily represent those of the Australian Government.
Table of Contents 1. Introduction ................................................................................... 6
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The social determinants of health.................................................................................. 7
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Beginning a healthy life - a best buy among the social determinants?.......................... 8
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Health, education and welfare perspectives on child development ............................. 12
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The Indigenous family context ..................................................................................... 13
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Family-centred primary health care: towards a definition ............................................ 15
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Methodology ................................................................................................................ 15
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Outline of report ........................................................................................................... 17
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2. Maternal and child health ............................................................ 19
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A summary of the evidence ......................................................................................... 20
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The Health of Indigenous Women and Children ...................................................... 20
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Intervention points for maternal and child health ......................................................... 21
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Interventions primarily focused on women before and during pregnancy................ 21
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Interventions primarily focused on the child after birth............................................. 25
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Home visiting programs ........................................................................................... 27
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Models in Aboriginal and Torres Strait Islander maternal and child health ................. 28
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Principles for success .............................................................................................. 31
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3. Education and Health ................................................................. 34
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A Summary of the Evidence ........................................................................................ 34
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The relationship between health and education ...................................................... 34
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The Australian Indigenous context........................................................................... 36
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Intervention points for education and health................................................................ 39
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Key features of interventions to enhance education outcomes ............................... 39
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Opportunities for a direct primary health care contribution ...................................... 42
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Models for Intervention ................................................................................................ 45
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Models from overseas.............................................................................................. 46
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Australian Models .................................................................................................... 48
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4. Health and Welfare ..................................................................... 51
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A summary of the evidence ......................................................................................... 51
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The health effects of child abuse and neglect.......................................................... 51
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The Australian Indigenous context........................................................................... 53
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Family welfare or child protection? .......................................................................... 55
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Intervention points for family and child welfare............................................................ 59
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Primary level interventions ....................................................................................... 60
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Secondary level interventions .................................................................................. 62
Tertiary level interventions ....................................................................................... 62
Factors for success in interventions......................................................................... 63
Models applied in primary health care......................................................................... 64
Opportunities for a primary health care contribution ................................................ 67
5. Implications for Primary Health Care .......................................... 70
Lessons for family-centred primary health care........................................................... 71
Core services for child development........................................................................ 72
Best Practice: primary health care professional practice ......................................... 74
A new model: child development centres .................................................................... 75
Background.............................................................................................................. 75
Child development centres: key concepts ............................................................... 76
6. Scale Up and Sustainability ........................................................ 80
Principles of sustainability ........................................................................................... 80
Models from other developed countries................................................................... 80
Models from international development ................................................................... 82
‘Scale up’: a system-wide approach to change ........................................................... 83
Mapping existing services and filling gaps............................................................... 83
Workforce................................................................................................................. 84
Prioritising child development research ................................................................... 85
Standards setting ..................................................................................................... 85
Changing expectations ............................................................................................ 85
Policy and community engagement ......................................................................... 86
Evaluation strategy .................................................................................................. 86
Next steps: child development centres........................................................................ 86
Resourcing the model and sustaining other services .............................................. 86
Workforce................................................................................................................. 87
Community engagement.......................................................................................... 87
Research and Evaluation......................................................................................... 87
Site selection for trials.............................................................................................. 88
Trial duration ............................................................................................................ 88
7. Bibliography ................................................................................ 90
FAMILY-CENTRED PRIMARY HEALTH CARE
Office for Aboriginal and Torres Strait Islander Health
1.
Introduction In contrast to general public perception, Indigenous health status has changed
significantly over the last century. Exactly when and in what way it has changed has
depended on locality – for example, the health history of the Aboriginal peoples of
south-eastern Australia is different to that of those in the north of the continent or to
those in the central deserts.
Broadly speaking, however, one of the key changes in the health of Aboriginal and
Torres Strait Islander communities since the 1960s has been the reduction in rates of
mortality (especially infant mortality) from infectious disease. Although changes such
as this are complex, the simple provision of improved access to medical services,
both government run and community-controlled, undoubtedly played an important
role.
Since then, the pattern of ill health in many communities has shifted to one
dominated by chronic disease and ‘life style’ conditions. While chronic disease has
complex causes, the evidence is beginning to accumulate that in some parts of the
country at least, mortality rates from chronic disease may be rising more slowly, or
even falling, and that better resourcing of primary health care systems and better
targeted programs to detect, treat and manage chronic disease are having an effect.1
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The management of chronic disease in a primary health care setting is now well
defined, extensively documented and based on good evidence. There is an important
body of work guiding Indigenous primary health care services in Australia in the
improvement of the management of chronic disease and the achievement of
secondary prevention outcomes.2 Significantly, contemporary thinking about chronic
disease management has moved beyond the concept of individual episodes of care
for a patient, to the development of long-term relationships with them, their family,
and their community.3
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It is not the primary focus of this current project to add to the body of work on chronic
disease management or, directly, to the improvement of secondary prevention
outcomes for Australian Indigenous people. Given the already extensive work in
these areas, this project could at best contribute to the margins of this field.
1
Thomas D, Condon J, Anderson I, Li S, Halpin S, Cunningham J and Guthridge S (2006) ‘Long-term trends in
Indigenous deaths from chronic diseases in the Northern Territory: a foot on the brake, a foot on the accelerator’ MJA
185:145–149
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2
Bailie R, Si D, O’Donohue L and Dowden M (2007) ‘Indigenous health: effective and sustainable health services
through continuous quality improvement’ MJA 186:525-528. See also the extension of the work described by Bailie et
al through the Support, Collection, Analysis and Reporting Function (SCARF) of the Australian Government’s Healthy
for Life program.
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3
Zwar N, Harris M, Griffiths R, Roland M, Dennis S, Powell Davies G, Hasan I (2006) A systematic review of chronic
disease management. Research Centre for Primary Health Care and Equity, School of Public Health and Community
Medicine, University of New South Wales.
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However, the very success of the secondary prevention of chronic disease highlights
the fact that among Aboriginal and Torres Strait Australians, primary prevention
approaches to chronic disease have struggled to make the same progress. This is
where, we argue, a family-centred primary health care approach can make a
significant contribution to the prevention of adult chronic disease. This will be the
focus of this report.
The social determinants of health A significant explanation for the relatively greater progress on secondary than
primary prevention in disadvantaged communities has emerged in the theory of the
social determinants of health. In essence, it states that many of the factors that
determine illness lie outside the conventional boundaries of primary clinical care.
Today in Western countries explanations of illness cast in terms of exposure to
certain individual risk-factors such as smoking, alcohol misuse, or being overweight
are a powerful way of understanding disease and illness in human populations and
have been the basis for many improvements in the health of populations, especially
when it comes to chronic disease.
However, in the last fifteen years or so, evidence has grown rapidly to show that in
addition to these individual causes lie other deeper causative factors: the so-called
social determinants of health. A person’s social and economic position in society,
their early life, exposure to stress, educational attainment, access or lack of it to
employment, their exclusion from participation in society and their access to food and
transport. All these exert a powerful influence on their health throughout their life.4
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The social determinants approach has generally been welcomed by the primary care
sector; after all, it fits well with a comprehensive approach to primary health care, and
in the Australian Indigenous environment in particular it is congruent with the holistic
approach to health developed by Indigenous communities and service providers.
However, this approach also presents a challenge: if good health requires addressing
the issues of poverty, education, life control, racism, housing, transport, addiction,
employment and all the other social determinants, what does that mean for primary
health care services? Clearly, many of these issues are beyond the direct
responsibility or competence of even the best and most comprehensive of primary
health care services, so how can they make the best contribution to addressing them,
and hence preventing illness across the whole population? Often the result is that, at
the same time as services and policy makers acknowledge the importance of the
4
For a concise examination of the social determinants of health, see Wilkinson R and Marmot M (1998) Social
Determinants of Health: the Solid Facts, World Health Organization Regional Office for Europe.
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social determinants of health, we consign them to the realm of background factors
that are too hard to address.5
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Beginning a healthy life ‐ a best buy among the social determinants? TP
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A number of the most important of the social determinants of health impact in early
life.6 The experience of the child, even while still within its mother’s body, is critical for
building a platform for a healthy life and deficits at this time are powerfully linked to
disadvantage and ill health later in life. This is the importance of “life-course” thinking
about health.
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These effects begin with the experience of the developing child in utero. The majority
of human embryos have the potential to be born into long and healthy lives.
However, from the moment of conception, this potential can be undermined by the
poor maternal health of the mother. Maternal smoking, alcohol consumption,
inadequate nutrition, maternal stress, illness and infection can all disrupt the
development of the child in utero7 and are associated (along with young maternal
age) to low birth weight of the baby.8
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Poor maternal health can reduce the number of foetal cells, interfering with the
development of the foetus’ organs or whole systems and leaving the child susceptible
to poor health from that time – not just in the womb, in infancy or childhood, but
throughout their life. It also appears that the immune system may also be affected by
early brain development. Disturbance of this pathway exacerbates the diseases that
these systems guard against such as infectious, inflammatory, autoimmune, and
associated mood disorders.9
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The time after birth is also a critical period for a child’s development and it appears
that brain development in the early years set pathways in brain development that
affect learning, health, and behaviour throughout the life cycle; a child lacking
5
Griew R and Weeramanthri T (2003) Investing in Prevention and Public Health in Northern Australia UK Australia
Seminar: Federalism, Financing and Public Health 14-16 September 2003, Nuffield Trust and Australian
Government, Canberra.
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6
The theory and evidence for the importance of the early years in the Australian context is importantly summarised in
Stanley F, Richardson S, and Prior M (2005) Children of the Lucky Country? How Australian society has turned its
back on children and why children matter. Macmillan. Sydney.
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7
Schultz R, Read A W, Straton A Y, Stanley F J, & Morich P (1991) ‘Genitourinary tract infections in pregnancy and
low birth weight’ BMJ 303:1369–1373. See also Gibbs R, Romero R, Hillier S L, Eschenbach D A, & Sweet R L
(1992) ‘A review of premature birth and subclinical infection’ American Journal of Obstetrics and Gynaecology
166:1515–1528.
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8
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AIHW 2005 op cit.
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9
Sternberg E (2000) The Balance Within: the Science Connecting Health and Emotions. WH Freeman and
Company. New York.
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positive stimulation or exposed to chronic stress in the first few years of life may face
life-long disadvantage.10
Poor experiences in brain development at this time can explain some of the major
behavioural problems children may face11; severe stress from adverse child
development environments has been shown to leave an indelible effect in brain
structure and function which in later life could appear as depression, anxiety, posttraumatic stress, aggression, impulsiveness, delinquency, hyperactivity or substance
abuse.12 There is evidence of a strong correlation between adverse early childhood
development such as neglect and abuse, and addiction to alcohol and drugs in later
life.13
Most importantly for this report, there now appears also to be a demonstrated
association between early childhood experience and the development of chronic
disease in adult life14, in particular a relationship between low birth weight and
increased rates of hypertension, coronary heart disease, diabetes and autoimmune
thyroid disease15 as well as an increased risk of hospitalisation and premature
death.16
This evidence of the life-long health and social effects of experiences in the early
years makes maternal and child health a critical intervention point for primary health
care services in tackling the social determinants of health. Indeed Australia’s first
comprehensive chronic disease prevention policy framework targeting Aboriginal
health, the NT Preventable Chronic Diseases Strategy, identified maternal and child
health as a best buy in chronic disease prevention.17
However, a life course approach to health cannot stop with maternal and infant
health. The implications of wider concepts of child development have achieved
increased prominence through the publication of key summaries such as From
10
McCain M N and Mustard F (1999) Early Years Study: Reversing the Real Brain Drain: Final Report. Ontario
Children's Secretariat, Government of Ontario.
11
Mustard J F (2006) Early Child Development and Experience-based Brain Development The Scientific
Underpinnings of the Importance of Early Child Development in a Globalized World. The World Bank International
Symposium on Early Child Development (September 27-29, 2005).
12
Teicher M H (2002) ‘Scars that won’t heal: The neurobiology of child abuse’ Scientific American (March):68-75
13
Felitti V J, Anda R F, Nordenberg D, Williamson D F, Spitz A M, Edwards V, Koss M P, and Marks J S, 1998,
‘Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults’
American Journal of Preventive Medicine 14(4).
14
See especially Barker D J, ed. (1993) Fetal and infant origins of adult disease. BMJ Publishing Group. London;
Barker D J (1998) Mothers and babies and health in later life. Churchill Livingstone. Edinburgh; and Panneth N and
Susser M (1995) ‘Early origin of coronary heart disease (the "Barker hypothesis")’ BMJ 310:411-412.
15
Eades S (2004) Maternal and Child Health Care Services: Actions in the Primary Health Care Setting to Improve
the Health of Aboriginal and Torres Strait Islander Women of Childbearing Age, Infants and Young Children
Aboriginal and Torres Strait Islander Primary Health Care Review: Consultant Report No 6 Commonwealth of
Australia.
16
Power C & Li L (2000) ‘Cohort study of birthweight, mortality, and disability’ BMJ 320:840–1.
17
Weeramanthri T, Morton S, Hendy S, Connors C, Rae C and Ashbridge D (1999) NT Preventable Chronic Disease
Strategy – Best Practice in Chronic Disease Control. Territory Health Services. Darwin
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Neurons to Neighbourhoods: the Science of Early Childhood Development.18 This
approach emphasises the continuous and accumulating interaction between biology
and experience, the importance of culture, the role of effective family relationships,
and the need for early intervention for high risk children and families.
This has led to a debate about the extent to which early experiences are modifiable
by later interventions: on the one hand, the so-called ‘latency model’ emphasises the
independent and long term effect of issues such as poor foetal development, low
birth weight and poor nutrition. On the other hand, a ‘pathways approach’
emphasises the on-going, cumulative nature of these deficits and acknowledges that
later interventions can ameliorate or even possibly overcome early developmental
deficits.19
One thing that has become clear is the crucial importance of socioeconomic status in
child development and health. While income is not the whole story, the ability to
ameliorate early disadvantage is highly mediated by socioeconomic status such that
there is a gradient in child development across the socioeconomic hierarchy. That is,
not only are there differences in morbidity and mortality between those at the top and
those at the bottom of the socioeconomic ladder but these differences exist across
relatively small increments in social hierarchy.
The important implication for governments and policy makers of this evidence is that
while those children at the lowest end of the socioeconomic scale stand to benefit
most from early intervention, it is arguable that all children can potentially benefit
from high quality programs. Conversely, vulnerable children are also the most
susceptible to the negative outcomes of poor quality programs.
While class determinants and whole-of-country income disparities are of over-riding
importance in life course health development, quality interventions and universal
programs that are well-resourced and expertly delivered, can counteract early setbacks. Children given access to excellent early child development centres, with
parenting support and involvement, will have better outcomes than children in similar
circumstances who are not given such access.20
The evidence for the benefits of this approach is strong. In a key publication, Lynn
Karoly21, examines in detail the costs and benefits in terms of Government
expenditure of two key early childhood interventions programs in the United States:
the Perry Preschool and the higher-risk families of the Elmira Parent/Early Infancy
18
Shonkoff J & Phillips D, eds, (2000) From Neurons to Neighbourhoods: The Science of Early Childhood
Development. National Academy Press. Washington DC.
19
Hertzman C, and Wiens M (1996) ‘Child development and long term outcomes: A population health perspective
and summary of successful interventions’ Social Science and Medicine 43 (7):1083-1095
20
McCain and Mustard 1999 op cit.
21
Karoly, L A (1998) Investing in Our Children: What We Know and Don't Know About the Costs and Benefits of
Early Childhood Interventions, Rand Corporation.
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Project. It was found that, for high risk families and children, benefits exceed the
costs by a factor of two or three to one, despite the fact that it was impossible to
quantify in monetary terms many of the benefits (for example, better relationships
between mothers and children). The savings to government resulted principally from
participating families requiring lower access to publicly funded services later in life
(for example health, special education, welfare and criminal justice services) but also
through greater economic independence of participants throughout their lives.
In Australia, a cost-benefit examination of early childhood interventions is hampered
by the almost total lack of evaluated programs. Thus a review of such interventions22
concluded that there is limited evidence that they can produce potential returns in
public investment. Nonetheless, there is no plausible reason why interventions in
child development in Australia would not evaluate equally well as sound investments
– which is why the Council of Australian Governments (COAG) committed in early
2006 to early childhood as a key component of its Human Capital Reform program.
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In its Communiqué, “COAG agreed that Human Capital Reform will be focussed first
and foremost on a limited number of outcomes, … (which) could include: …
•
a reduction in the prevalence of key risk factors that contribute to chronic
disease;
•
a reduction in the incidence of chronic disease; …
•
an increase in the proportion of children entering school with basic skills for
life and learning;
•
an increase in the proportion of young people meeting basic literacy and
numeracy standards, and improved overall levels of achievement…”23
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Such an approach, based on child development principles is simply put, the ‘best
buy’ for governments whose investment in primary health care goes beyond the
provision of medical care to address the health of populations, now and into the
future.
22
Wise S, da Silva L, Webster E, Sanson A (2005) The efficacy of early childhood interventions. Australian Institute
of Family Studies Research Report No. 14, July 2005
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23
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Council of Australian Governments (2006) A New National Reform Agenda – Communiqué, 10 February 2006.
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Health, education and welfare perspectives on child development A broad early childhood development perspective sees the antenatal, family and
social environments as all critical in shaping young children’s social, developmental
and cognitive capacities.24 However, the very breadth of this vision has lead to
difficulties in adopting a unified approach to child development.
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While the different disciplines, professions and knowledge systems that claim
expertise about children share an interest in child development, each has also a set
of assumptions, interests and protective behaviours that serve to inhibit a more
integrated approach to child development. Child health, education and welfare
professionals look through different prisms at the same subject – the child and his or
her development – but the prisms come to separate rather than unite their insights
and their practice. As Shonkoff and Phillips put it,
Closely related to the diversity of early childhood programs is the extent to
which interventions are defined differently depending on the disciplinary lens
through which they are viewed. Early intervention is a collection of service
systems whose roots extend deeply into a variety of professional domains,
including health, education, and social services … It is a field whose
knowledge base has been shaped by a diversity of theoretical frameworks
and scientific traditions, from the instruction-oriented approach of education
… to the psychodynamic approach of mental health services … and from the
conceptual models of developmental therapies ... to the randomized control
trials of clinical medicine …
At its best, early intervention embodies a rich and dynamic example of
multidisciplinary collaboration. Less constructively, it can reflect narrow
parochial interests that invest more energy in the protection of professional
turf than in serving the best interests of children and families. 25
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Head Start in the USA and a number of other innovative programs grew out of the
desire for an integrated approach to child development in an environment that did not
provide anywhere like adequate basic service access for poor families.
In Australia it is arguable that, despite (or perhaps because of) better basic service
infrastructure we have been less successful at integrating service silos to create
integrated early childhood services. This frustration is possibly one of the drivers
24
RCH (Royal Children's Hospital) (2006) Policy Brief No 1 Early childhood and the life course. Available:
www.rch.org.au/ccch.
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25
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Shonkoff & Phillips 2000 op cit, p339
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behind Australian heads of government designing the COAG Human Capital early
childhood stream from 2006.
Were the creation of a new child development approach to be undertaken from a
clean slate, no-one would argue for as divided an early childhood field as we have
currently. We understand the benefits of clear disciplinary knowledge and demarked
fields of service provision, especially in the testing environments in which service
providers to disadvantaged children operate. However, family life and child
development in such environments require both better linkages and a more
integrated understanding of the child and his or her family. In short we need
professionals and policy makers to act in the knowledge that we are all simply
looking through different prisms at the same children and families.
In this report we will consider both how the service silos and professions can work
together more effectively, and in particular at the role that primary health care can
play, but also we will take the opportunity to envisage a service system where the
boundaries between the service silos and professions are substantially dissolved and
new service forms for Australian Indigenous families can be developed.
The Indigenous family context The likely value of child development as a life course investment in Aboriginal and
Torres Strait Islander families is strengthened by an examination of the Indigenous
family context.26
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The Australian Indigenous population is younger and the fertility rate higher than for
the rest of the population. In 2001, Indigenous children aged 0–14 years accounted
for 39% of the Indigenous Australian population. At the 2001 census there were
about 179,000 Indigenous Australian children. These children made up 4.5% of the
total Australian child population in 2001.27
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Household composition and the family environment is often more complex in families
with Aboriginal children. The best data on Aboriginal family life comes from the West
Australian Aboriginal Child Health Survey (WAACHS).28 This found that one in 12
households had Aboriginal children being primarily cared for by aunts, grandparents
and other extended family and non-family members. This household arrangement
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26
Note that for ease of expression in this report, we use the terms ‘Aboriginal’, ‘Indigenous’, and ‘Aboriginal and
Torres Strait Islander’ interchangeably to refer to Australia’s Indigenous peoples, unless specifically noted otherwise.
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27
AIHW (Australian Institute of Health and Welfare) (2005) A picture of Australia’s children, AIHW cat. no. PHE 58.
Canberra.
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28
Zubrick S R, Lawrence D M, Silburn S R, Blair E, Milroy H, Wilkes T, Eades S, D’Antoine H, Read A, Ishiguchi P &
Doyle S (2004) The Western Australian Aboriginal Child Health Survey: The Health of Aboriginal Children and Young
People, Telethon Institute for Child Health Research, Perth. Available:
http://www2.ichr.uwa.edu.au/waachs/?q=/waachs/
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has been shown to place children at a higher risk of emotional or behavioural
difficulties and lower academic performance.
WAACHS also found that the primary carers in these households are less likely to
have had the full benefits of education – compared with the general population,
carers of Aboriginal children have lower levels of education with approximately one
third of carers of Aboriginal children having left school before completing Year 10.
Approximately 15% of dwellings with Aboriginal children are overcrowded, and about
the same proportion have poor housing quality. Aboriginal family mobility in West
Australia was also found to be elevated, with Aboriginal children aged 6 years having
lived in an average of 3.2 homes.
Families of Aboriginal children report much higher levels of stress caused by deaths
in the family or community, incarceration, violence and severe hardship. WAACHS
reported that 22% of Aboriginal children aged 0-17 years were living in families
where 7-14 major life stress events had occurred in the 12 months prior to the survey
and the two major factors associated with families experiencing so many stressful
events were family financial strain and the number of neighbourhood problems
reported by the primary carer.
Poor family functioning was also associated with family financial strain which is
present in over half of families with Aboriginal children in Western Australia. The
quality of the child’s diet was also independently associated with poor family
functioning.
Aboriginal and Torres Strait Islander families are disrupted also to a higher extent by
the imprisonment of both men and women at rates 16 times higher for men and 23
times higher for women than other Australians. Australian women are imprisoned on
average at a rate of 16 women per 100,000 of the adult female population.
Indigenous women however are imprisoned at a rate of 366 per 100,000 of the adult
female population. Imprisonment of all women is also rising annually.29
The above information on the experience of Indigenous families and households,
reinforces the importance of ameliorating the ways in which family disadvantage and
stress impact on Indigenous children’s development, even from before they are born.
29
ABS (Australian Bureau of Statistics) (2006) Prisoners in Australia Catalogue no 4517.0. See also Krieg A, 2006,
Aboriginal incarceration: health and social impacts MJA 184:534-536
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Family‐centred primary health care: towards a definition The realities of Aboriginal family life outlined above have important implications for
primary health care services and policy makers in developing a family-centred
approach.
To the extent that family-centred primary health care is about giving Aboriginal
people the best platform for health over the life course, this means being wary of
assumptions about the construction of families in the development family-centred
services.
For this project the Aboriginal or Torres Strait Islander “family” in family-centred
primary health care is not limited either to an assumption of a nuclear family – clearly
it is necessary for health care providers to assume that Indigenous children will often
have other significant carers than just their biological mother and father.
It is also necessary to understand that, although there is a biological importance of
maternal health, children are part of a family system, with fathers, aunts, uncles,
grandparents and other siblings (and their own health issues) often key to
determining the outcome of child development and resilience.
There is no widely-agreed definition of what constitutes ‘family-centred primary health
care’. For the reasons explained above, this project will take it to be more than about
a family friendly feeling to primary health care, or even family focused clinical
practice. Instead we propose a two part definition as follows:
1. Family-centred primary health care moves beyond providing care to the
individual patient, to seeing them as being embedded in a family and
providing services on that basis; and
2. Family-centred primary health care takes a life course approach, which,
without neglecting adult health, focuses specific attention on establishing
early life resilience and advantages through a focus on child development.
In this sense family-centred primary health care involves an attempt to draw two
areas normally considered only as part of the “social determinants of health”
background, education and family welfare, into the foreground of primary health care
practice.
Methodology This review was commissioned by the Office for Aboriginal and Torres Strait Islander
Health from a team headed by Associate Professor Robert Griew, Managing Director
of Robert Griew Consulting, together with JTAI Pty Ltd and a number of individual
experts in Aboriginal and Torres Strait Islander programs as follows:
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•
Professor Sandra Eades, the head of Aboriginal health at the Sax Institute
and an expert in Aboriginal maternal and child health;
•
Associate Professor Tess Lea, co-director of the School of Social Policy
Research at the Charles Darwin University and an expert in Indigenous
education policy; and
•
Ms Carol Peltola, an expert in child and family welfare, with a strong
background in Indigenous welfare issues.
JTAI is a firm specialising in community and primary health care development in the
Asia Pacific region, also working in Indigenous health in Australia.
Although the primary source informing this report was the published literature, the
review team also sought specific views from experienced professionals in both nonGovernment and Government health and welfare sectors. We gratefully acknowledge
their contribution. We would also like to acknowledge the constructive comments
from Australian Government officials and in particular Ms Anne Clarke of the Office
for Aboriginal and Torres Strait Islander Health. Of course, the report remains the
product of the review team and does not necessarily represent the views of those
who assisted us or of the Australian Government.
The research approach used was for the core team from Robert Griew Consulting to
seek from the other experts in the team a set of key resources covering child health,
education and welfare, with a focus on Indigenous children in Australia and overseas.
As well, websites and other informants were interrogated, including through the Sax
Institute and the collaboration between the School of Social Policy Research and the
Menzies School of Health Research.
The material accessed included a number of other reviews that have been
undertaken in Indigenous maternal and child health and education. This allows the
Chapters analysing these two areas to rely more heavily on secondary sources.
There was less such material accessed in Indigenous child and family welfare and
the team found less well developed analysis to support exploration of the relationship
specifically between child and family welfare and health. For this reason the Chapter
covering this area relies more on primary source material and the team’s own
analysis of child protection data.
This report has been prepared as a review, targeting policy makers, of what matters
in the literature, rather than as a systematic or meta review of the literature. It
includes material from the world of professional practice that would not necessarily
be included in a systematic review and does not include all of the vast literatures in
the three fields traversed.
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The aim is to give the policy maker a clear picture of the literature and experience
that should sensibly be taken into account from across three policy and professional
domains that we know are related to each other but which have been hard to unite in
practice.
Outline of report The aim of this report is to outline the evidence as to how child development impacts
on health over the life course, and to explore the implications for primary health care
practice and policy.
The contract of engagement from the Australian Government Department of Health
and Ageing directed the team to provide a detailed review of the literature on current
family-centred primary health care service delivery approaches, focussing on children
between 0 and 8 years and their families within Indigenous populations, and
evaluations of any models, programs or approaches. This was to be accompanied by
a report documenting the key elements relevant to the evolution of best practice in
service delivery, and recommendations on strategies and priorities for further
development of identified best practice models, for both mainstream and Indigenous
specific services. With the agreement of the Department both the review of the
relevant literature and the written report with recommended ways forward are
included in this report.
In overview, the structure of this report is as follows.
Following this introductory chapter there are chapters outlining the evidence on
maternal and child health, the relationship between health and education, and health
and family welfare. Each of these chapters outlines the lessons from the leading
articles in the scientific literature and from accounts of professional practice.
In Chapter Two, we examine the first of our three domains – maternal and child
health. This is commonly conceived as already being an important part of a
comprehensive model of primary health care. We provide a summary of the evidence
about the menu of required service delivery and interventions for mothers and young
children, together with the challenges that taking a child development focus and a
family-centred clinical approach raise for this service menu.
In Chapter Three, we look at the relationship between education and health. This is
the second domain, and one where key service provision stands outside the primary
health care sector. We provide a summary of the evidence on the relationship
between education outcomes and health outcomes and what interventions and
principles are important, before looking at the challenges that this raises for primary
health care practice – how can primary health care ‘complete the circuit’ and help
ensure that Aboriginal children gain the health benefits of education?
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Chapter Four examines our third key domain that is also conventionally seen as
outside the primary health care sector: child and family welfare. Here again we
present a summary of the evidence about the relationship between family welfare
and child health and development, the current challenges in child protection and
once again what opportunity these throw up for primary health care practice.
Two further chapters spell out the implications of the evidence summarised in
Chapters Two, Three and Four.
Chapter Five brings together the evidence from the three domains of maternal and
child health, education and health, and welfare and health to look in detail at the
implications of the evidence for primary health care practice.
This chapter raises two possible models for reform: the first assuming the continued
existence of three separate service systems in health, education and welfare; and the
second a more radical model proposing an integrated model of family-centred service
that integrates a range of services. Such an approach is consistent with recent key
documents in this area, in particular the Little Children are Sacred report
commissioned by the Northern Territory Government’s30, and the Australian
Government’s Indigenous Child Care Services Plan31.
Critically, we argue that this model of integrated, holistic early childhood services is
worth piloting in a number of robust service settings.
Finally in Chapter Six, we look at meeting the challenge of ‘scale up’ and
sustainability for both of the models presented in Chapter Five, outlining the
considerations relevant to implementation beyond the creation of small scale
excellent services, to system wide reform. Issues canvassed include workforce,
funding models, standards development, institutional and professional change
processes, community engagement, site selection and evaluation strategy.
30
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.
31
Australian Government (2007) The Indigenous Child Care Services Plan August 2007. Department of Families,
Community Services and Indigenous Affairs. Commonwealth of Australia. Canberra. See also Australian Government
(2007) Towards an Indigenous Child Care Services Plan: a summary of the findings from consultations with
Indigenous Communities 2005-06. Department of Families, Community Services and Indigenous Affairs.
Commonwealth of Australia. Canberra.
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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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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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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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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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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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AIHW 2005 op cit p33
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.
U
U
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
HT
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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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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4.
Health and Welfare Child and family welfare is the second of the domains often consigned to the “social
determinants of health” to bring forward to a more “core” place in primary health care.
In the previous chapter we considered the relationship between health and
education. We started with a review of the evidence as to why education and health
outcomes are synergistic and of the current state of Aboriginal and Torres Strait
Islander education in Australia. We then identified intervention points for improving
education outcomes and the implications of these for primary health care practice.
Finally we reviewed a number of models that have linked education and health
outcomes for disadvantaged children.
We will argue that, important though current statutory child protection services are,
they are not constructed or equipped to fulfill the wider role of improving family
welfare. While it is not practical for primary health care services, schools or child care
services to take on the business of statutory forensic child protection, primary health
care services (and other social agencies) can play a vital role in family welfare. This
role is key to successful child development outcomes that will, in turn, result in better
health outcomes across the life course.
A summary of the evidence In the literature, definitions of what constitutes family and child welfare vary
considerably. However in its broadest sense, child welfare and protection are
concerned with preventing trauma or insult to normal childhood development.
There are a number of reasons why family and child welfare matters for this report.
First there are direct and long term health consequences of family and child welfare.
Second, Aboriginal and Torres Strait Islander children are strongly overrepresented
in the current child protection systems. Third, we will argue that child protection
services in the current environment are unable to provide adequate support to
broader child and family welfare, which means input is needed from other sectors,
such as primary health care services.
The health effects of child abuse and neglect Child abuse and neglect have both direct and indirect health consequences. As well
as the immediate effects of abuse and neglect, there are long term impacts on the
developing brain and physiology which change developmental structures and
pathways, physically and hormonally.
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Life course risk of chronic disease The leading causes of morbidity and mortality world-wide are related to health
behaviours and lifestyle factors. Damaging childhood experiences such as abuse and
neglect contribute to the development of these risk factors.
Felitti’s critical 1998 study147 compared people who had experienced four or more
categories of childhood exposure including physiological, physical, and sexual abuse,
or household dysfunction (such as substance abuse, mental illness, domestic
violence and criminal activity in the home) with those who had experienced none. It
found a four to twelve-fold increased health risk for alcoholism, drug abuse,
depression, and suicide attempt; a two to four-fold increase in smoking, poor selfrated health, and increased chance of 50 or more sexual intercourse partners and
sexually transmitted disease. In addition, they had a 1.4 to 1.6-fold increase in
physical inactivity and severe obesity.
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The number of categories of adverse childhood exposures showed a graded
relationship to the presence of adult diseases including ischemic heart disease,
cancer, chronic lung disease, skeletal fractures, and liver disease. The seven
categories of adverse childhood experiences were strongly interrelated and persons
with multiple categories of childhood exposure were likely to have multiple health risk
factors later in life.
Direct health outcomes from child abuse and neglect The potential consequences of child maltreatment involve long-term health effects
and developmental delays. Some of these long-term outcomes result from specific
injuries and aggressive actions; other effects result from the absence of positive
interactions between parents and their children and the lack of response to a child’s
basic physical and emotional needs.
Research has also shown the association between child maltreatment and various
types of brain injuries particularly in the first 3 years of life148, as well as neuromotor
handicaps149, and mental health disorders such as heightened levels of depression,
hopelessness and low self-esteem.150 Child and adolescent sexual abuse is also
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147
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Felitti et al 1998 op cit.
148
Guterman N B (2001) Stopping child maltreatment before it starts: Emerging horizons in early home visitation
services. Sage Publications. Thousand Oaks, California.
149
Green A H, Gaines R W & Sandgrund A (1974) ‘Child abuse: pathological syndrome of family interaction’
American Journal of Psychiatry 131(8): 882-886
150
Guterman 2001 op cit
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associated with the risk of sexually transmitted diseases151 and post-traumatic stress
disorder in childhood and later in adult life.152
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Cognitive and educational attainment Some research studies have found associations between child maltreatment and
language deficits, reduced cognitive functioning153 and attention deficit disorders154,
which results in poorer retention rates in school and lower school achievement155,
which as we have seen in the previous chapter, are also risks for subsequent health
outcomes.
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Social and behavioural development Chalk et al 156 reviewed the evidence on the impact of child maltreatment on social
and behavioural development, with two of the most consistent outcomes being
antisocial behaviour and physical aggression as well as fear, anger and selfdestructive behaviour. Maltreatment can also have a negative impact on emotional
stability and self-regulation, problem solving skills, and the ability to cope with or
adapt to new situations which can lead to problems developing trusting relationships.
Child sexual abuse is reported as a risk factor for adolescent pregnancy and for
getting into trouble with the criminal justice system.
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The Australian Indigenous context Rates of abuse and neglect are obviously a serious concern across the whole
population but especially so among Aboriginal and Torres Strait Islander children.
In 2005-06, across Australia there were just over 6,000 substantiated cases of abuse
or neglect of Indigenous children, a rate of almost 30 cases per 1,000 children – four
and a half times the rate amongst non-Indigenous children157. The rates of
Indigenous children on care and protection orders were more than 6 times higher
than for other children. The rate of Aboriginal and Torres Strait Islander children in
out-of-home care was over 7 times the rate of other children.158
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151
National Research Council (1993) Understanding child abuse and neglect. National Academy Press, Washington
DC.
152
Wyatt G E (1992) ‘The sociocultural context of African American and white American women's rape’ Journal of
Social Issues 48:77-91
153
Augoustinos M (1987) ‘Developmental effects of child abuse: a number of recent findings’ Child Abuse and
Neglect 11:15-27;
154
National Research Council 1993 op cit.
155
Eckenrode J, Laird M, & Doris J (1991) Maltreatment and social adjustment of school children (Grant 90CA1305,
National Center on Child Abuse and Neglect). U.S. Department of Health and Human Services. Washington DC.
156
Chalk R, Gibbons A, & Scarupa H J (2002) The Multiple Dimensions of Child Abuse and Neglect :New Insights
into an Old Problem. Child Trends Research Brief. Washington DC.
157
AIHW (Australian Institute of Health and Welfare) (2007) Child protection Australia 2005–06. AIHW Cat. no. CWS
28. Canberra, p 27.
158
ibid Table 4.8
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Indigenous children are significantly over-represented in most statutory child
protection systems and to this extent their issues should be a priority of mainstream
child protection services.159
In most jurisdictions, emotional abuse and neglect of Indigenous children formed the
great majority of substantiated cases (typically between 70% and 90%, somewhat
higher than for the non-Indigenous population), with sexual abuse generally being a
serious but relatively small minority of substantiations160.
To date, the most comprehensive investigation into Aboriginal child mental health
comes from the Western Australian Aboriginal Child Health Survey (WAACHS). Data
was collected on 5289 Aboriginal children aged 0-17 living throughout Western
Australia and found almost a quarter (24%) of the children surveyed were at a high
risk of clinically significant emotional or behavioural difficulties, compared to 15%
non-Indigenous children.161
Results of the WAACHS indicated that the strongest predictor of emotional or
behavioural problems amongst the children studied was the number of major life
stressors experienced by the child’s family in the year prior to interview. Poor quality
parenting, poor family functioning, being under the care of a sole parent, or under the
care of people other than the biological parent/s, having lived in more than 5 homes
since birth and having a primary carer who had had contact with mental health
services, were all also significant predictors of mental health problems. Children who
were primarily cared for by an adult who had been forcibly removed from their own
biological family were found to exhibit poorer outcomes than others in terms of
emotional and behavioural problems and drug and alcohol use, illustrating the
ongoing harms associated with the ‘stolen generation’. These findings highlight the
critical importance of assessing carer health and family factors when considering the
mental health of children.
It is now generally accepted also that both forced separation and forced relocation
have had devastating consequences on Indigenous families in terms of social and
cultural dislocation and have impacted on the health and well being of subsequent
generations. Recent research evidence has provided scientific quantification for the
nature and extent of these intergenerational effects.162
159
Stanley J, Tomison A M & Pocock J (2003) Child abuse and neglect in Indigenous Australian communities.
National Child Protection Clearinghouse Issues Paper No.19. Australian Institute of Family Studies. Melbourne.
Available: http://www.aifs.gov.au/nch/pubs/newsletters.html
160
AIHW 2007 op cit. p 29
161
Zubrick et al 2004 op cit.
162
Pearson G, Griffin J A, Zubrick S R, Lawrence D M, DeMaio J A, Blair E, Silburn S R, Dalby R B, Cox A, Mitrou F
G & Hayward C (2006) ‘The Intergenerational Effects of Forced Separation on the Social and Emotional Wellbeing of
Aboriginal Children and Young People’ Family Matters: Newsletter of the Australian Institute of Family Studies 75: 1017. Available: <http://search.informit.com.au/documentSummary;dn=346945332040849;res=E-LIBRARY)
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Researchers and advocates have argued that child abuse and neglect associated
with Indigenous communities cannot be understood, nor addressed, unless it is
viewed from a broad perspective which includes both historical and present day
issues. Measures centred around community-based responses which empower
Indigenous Australians are needed, in order to protect Indigenous children from the
serious levels of abuse which they are presently experiencing.163 General risk factors
for child maltreatment which can be the result of the historical Indigenous context
include low income, substance abuse, mental health problems, intellectual disability
and family violence, poor parenting and social isolation.164
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Family welfare or child protection? The argument of those researchers and advocates who argue that addressing child
abuse and neglect in Indigenous communities requires a move from an individualistic
and investigation driven model toward one that focuses on strengthening families,
communities and the environment in which they live reflects a wider analysis of child
protection policy and practice.165
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As noted above, this chapter is mainly concerned with the creation of services
complementary to forensic statutory child protection. However, a review of some of
the key changes in child protection results provides the context in which these
services must be envisaged and developed.
Each year the Australian Institute of Health and Welfare (AIHW) collects data on child
welfare and protection from the relevant departments in each state and territory on
child protection notifications, investigations and substantiations; children on care and
protection orders; and children in out-of-home care. However, there is no data at the
national level on children who are referred to or who access other services for
protective reasons.
According to this data:
•
the number of child protection notifications in Australia has almost doubled
from 137,938 in 2001–02 to 266,745 in 2005–06166;
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Stanley et al 2003 op cit.
164
Geeraert L, Van den Noortgate W, Grietens H, & Onghena P (2004) ‘The Effects of Early Prevention Programs for
Families with Young Children at Risk for Physical Child Abuse and Neglect: A Meta-Analysis’ Child Maltreatment
9:277-291.
165
See for example: PeakCare Queensland (2007) Rethinking Child Protection: A New Paradigm? PeakCare
Discussion Paper No 5 Queensland; Tilbury C (2003) ‘Repeated Reports to Child Protection: Interpreting the data’
Children Australia 28(3); Liddell M, Donegan T, Goddard C & Tucci J (2006) The State of Child Protection: Australian
Child Welfare and Child Protection Developments 2005. National Research Centre for the Prevention of Child Abuse,
Monash University and Australian Childhood Foundation. Melbourne.
166
AIHW 2007 op cit. Table 2.3 p x
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•
the number of substantiations in most jurisdictions also increased over the
last 5 years;
•
nationally, the number of children in out-of-home care rose each year from
1996 to 2006;
•
the numbers of children in care increased by 35% from 18,880 at 30 June
2002 to 25,454 at 30 June 2006;167 and
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the rates of children in out-of-home care in Australia increased from 3.9 per
1,000 at 30 June 2002 to 5.3 per 1,000 at 30 June 2006.168
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This dramatic increase in all of the collected indices raises important questions about
the reasons for the increases and about the capacity of child protections systems to
address the broader needs of children and families, given their current focus on
investigative, incident based models.
In addressing these questions, the AIHW suggest that169:
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The definition of what constitutes child abuse and neglect has changed and
broadened over the last decade. Naturally, any broadening of the definition of
child abuse and neglect is likely to result in increasing notifications and
substantiations. The focus of child protection in many jurisdictions has shifted
away from the identification and investigation of narrowly defined incidents of
child abuse and neglect towards a broader assessment of whether a child or
young person has suffered harm. This broader approach seeks to assess the
child’s protective needs.
This explanation reflects the input of State and Territory child protection agencies but
may be only a part of the story.
Over the same period many States and Territories have experienced crises in their
child protection systems with wide media and political coverage of breakdowns and
catastrophic outcomes for numbers of children.
This has led to a significant increase in investment but also in a lessening of the
tolerance of risk, in an environment where child protection professionals are
continually having to make difficult risk based decisions about individual families. It is
not clear that the extra funding has been applied to a wider range of early
intervention and preventive services, at least in proportion to the overall increase in
funding.
167
ibid Table 4.3
168
ibid Table 4.7
169
ibid p 6
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As noted there is no national data on the proportion of notifications that lead to non
statutory referrals or “other” services. However, one way to evaluate this is to
examine the reporting of re-substantiations, that is, the proportion of children who
have been the subject of multiple substantiated findings. This is often interpreted as
an indication of a failure in child protection practice and systems, although it may also
be a measure of the failure to offer the families involved adequate support to
continue, or re-establish, parenting. On this point, AIHW cite a report prepared for the
Victorian Department of Human Services in 2002170:
The study found that key underlying features, such as low income, substance
abuse, mental health issues and the burdens of sole parenting, which led to
some families coming into contact with child protection systems, were
complex and chronic. The child protection system often did not effectively
deal with these problems and many children were subject to resubstantiations. The report noted that helping families to deal with these
problems required more sustained and less intrusive support than the
services usually provided by child protection authorities. It highlighted the
need for strengthened prevention and early intervention services as well as
improved service responses for children with longer-term involvement in the
child protection system.”
The final piece of relevant information from child protection collections that supports
a shift in the balance toward early intervention and prevention is the kind of abuse or
neglect experienced by children in the child protection system (see table).
170
ibid p 7
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Emotional abuse and neglect of Indigenous children formed the great majority of
substantiated cases.171 However the AIHW report that ‘the high proportion of
substantiations of emotional abuse is a relatively new phenomenon … in 1998-99,
physical abuse was the most common form’
The reason that this is important is that, while with physical and sexual abuse are
somewhat amenable to an incident based investigative model, the damage of
emotional abuse and neglect is harder to tie to an incident and is even more often
indicative of other health and family issues.
The appropriate responses to emotional abuse and neglect are also less often
available to child protection authorities as these phenomena even more often result
from other health issues in the child’s family (such as mental health and drug and
alcohol problems) or from environmental problems (such as poverty or lack of food
supply.)172 For example, a critique of Growth Assessment and Action in the Northern
Territory was that, in the absence of public health responses to these issues, all it
achieved was the removal of Aboriginal children from their families as a result of
substantiated findings of neglect.173
171
ibid p 29
172
Liddell et al 2006 op cit.
173
J Vadiveloo, NT NGO child protection expert, personal communication
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Again, to quote the AIHW report174:
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The changing pattern of type of abuse may be due to the changing
characteristics of the families notified. For example, a Victorian study in 2002
showed that in 2001–02, at least 73% of the parents of children in
substantiated cases in Victoria had at least one issue or problem such as
domestic violence, alcohol or substance abuse or a psychiatric disability. This
is a large increase from the 41% of parents that experienced these difficulties
in 1996–97.
Obviously, the role and work of statutory child protection agencies remains essential.
However, it is clear that for Indigenous children especially, given their overrepresentation in the child protection system and the patterns of problems they and
their families confront, effective family support interventions are essential. These
require action on the part of primary health care and other social services, beyond
the limited responsibility to participate in notification and investigation processes.
Intervention points for family and child welfare There are a number of ways to categorise possible points of intervention to
strengthen family and child welfare. The Gordon Inquiry in WA adopted an ecological
framework which attempted to capture the range of factors which can be important:
these are represented in the table below.175
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This approach is broadly consistent with the well accepted application public health
framework that distinguishes primary, secondary and tertiary prevention.
Primary prevention interventions seek to act on causal factors to prevent the
development of problems; secondary prevention interventions act at an early stage
on problems that have been established to reverse them or prevent further problems
that often result; and tertiary prevention interventions are rehabilitative in focus –
seeking to reverse damage done. This model was applied in a 2005 report by the
Centre for Health Services Development.176
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174
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AIHW 2007 op cit p 24
175
Gordon S, Hallahan K & Henry D (2002) Putting the picture together: Inquiry into Response by Government
Agencies to Complaints of Family Violence and Child Abuse in Aboriginal Communities. WA Department of Premier
and Cabinet. Perth. Available: www.premier.wa.gov.au/feature_stories/gordoninquiryreport.pdf at electronic page 83
176
Eager et al 2005 op cit.
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Primary level interventions At the first level, primary preventive efforts are aimed at all children and their parents
and include efforts to enhance parenting skills and provide children with knowledge
and assertiveness training.
Parenting programs Parenting programs variously include combinations of information sessions, support
groups, home visits and are also sometimes combined with access to quality child
care, structured playgroups and other interventions focusing on the child. Shonkoff
and Phillips argue that:
Generally speaking, programs that offer both a parent and a child component
appear to be the most successful in promoting long-term developmental gains
for children from low income families.177
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A high profile example is the Positive Parenting Program (although this program also
include tiered levels of intervention including more intensive therapeutic options for
families with problems in child behaviour and parental coping.) The program,
developed at the University of Queensland and adopted widely in Australia and
177
Shonkoff and Phillips 2000 op cit. p 345
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overseas, has been positively evaluated using RCT standard review and the specific
content of each level is manualised with professional training provided.178
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Child education programs Child education programs aim to provide children with skills to protect themselves.
According to a recent systematic review, such programs can increase child
disclosure of physical abuse and neglect.179 While there is little evidence that child
education programs by themselves can prevent the initiation of abuse, particularly
within the family, they have proved most useful in helping to prevent the recurrence
of maltreatment by encouraging children to report incidences of abuse. 180
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Welfare reform Primary prevention interventions also seek to change the underlying causes of
problems, raising the possibility of welfare reform initiatives making a contribution to
family and child welfare by aiming to transition welfare dependent parents to the
workforce.
A 2004 report that focused on the question of whether and how pilot welfare reform
programs launched in five U.S. States – Connecticut, Florida, Indiana, Iowa, and
Minnesota – affected children’s developmental outcomes. The report looked first at
adult economic outcomes that the programs aimed to change (targeted outcomes),
then turned to aspects of young children’s lives – including child care and the home
environment – and finally on children themselves.181 It concluded that there was little
evidence that these welfare reform programs resulted in either widespread harm or
benefit to young school-age children but that they were more likely to have
statistically significant impacts on targeted outcomes for adults – employment,
earnings, welfare receipt, and income. Positive impacts on children’s functioning
appear to be related to increases in family income. Most of the programs showed
only a few impacts (given the number of measures examined) on aspects of family
life, such as stability or turbulence, parenting, the home environment, and the
parent’s psychological well-being.
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178
Sanders M R (2003) 'The Triple P-Positive Parenting Program: A Universal Population-Level Approach to the
Prevention of Child Abuse' Child Abuse Review 12:155-171. For a similarly well evaluated U.S. example see Margolis
P A, Stevens R, Bordley W C, Stuart J, Harlan C, Keyes-Elstein L, & Wisseh S (2001) ‘From Concept to Application:
The Impact of a Community-Wide Intervention to Improve the Delivery of Preventive Services to Children’ Pediatrics
108(3).
179
Kaplan S J, Pelcovitz D & Labruna V (1999) ‘Child and adolescent abuse and neglect research: a review of the
past 10 years. Part I: physical and emotional abuse and neglect’ Journal of the American Academy of Child and
Adolescent Psychiatry 38:1214–1222.
180
Kovacs K & Tomison A (2003) ‘An analysis of current Australian program initiatives for children exposed to
domestic violence’ Australian Journal of Social Issues 38(4):513-530
181
Tout K, Brooks J, Zaslow M, Redd Z, Moore K, McGarvey A, McGroder S, Gennetian L, Morris P, Ross C &
Beecroft E (2004) Welfare Reform and Children: A Synthesis of Impacts in Five States (The Project on State-Level
Child Outcomes). U.S. Department of Health and Human Services. Available:
www.acf.hhs.gov/programs/opre/welfare_employ/ch_outcomes/index.html.
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Secondary level interventions At the second level, families at risk are offered additional support through home
visiting or parent training. Various screening and evaluation methods have been
evaluated.
In a meta-analysis of 43 studies, early intervention programs were found to reduce
the incidence of abusive acts and increase parenting skills and parental social
networks. Most programs involved some form of home visiting by professionals or
para-professionals.182
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As noted in Chapter Two, the literature on home visiting is more extensive, including
some large-scale randomised controlled trials with long-term follow up, which have
demonstrated that home visiting by professionals has benefits for at least specific
groups of at-risk families.183 The presence of domestic violence may limit their
effectiveness.184 Enhanced home visiting, including specific retraining interventions
for mothers, may also be more effective.185 The Triple P program has also been used
with higher risk families, with some success186 although as the degree of trauma
experienced by children in abusive environments increases, there is a competing
school of thought that models such as PPP will be less successful in the long term
than therapeutic approaches that directly address the attachment disorders that
result from this trauma.187
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According to the CHSD report, available standardised tools for screening for child
abuse have limited efficacy. A set of early indicators of child abuse based on clinical
experience has consensus support from academics and practitioners in Britain but it
is unclear how useful these might be in the Australian context.
Tertiary level interventions Tertiary prevention involves minimising harm to children in cases of confirmed abuse.
This is the largest and most diverse group of interventions, incorporating various
types of therapeutic support for abused children, education or counseling for abusive
and non-offending parents, and support for foster parents or the family of origin.
182
Geeraert et al 2004 op cit.
183
For example Armstrong K L, Fraser J A, Dadds M R & Morris J (1999) ‘A randomized, controlled trial of nurse
home visiting to vulnerable families with newborns’ Journal of Paediatric Child Health 35:237-244; MacLeod J and
Nelson G (2000) ‘Programs for the promotion of family wellness and the prevention of child maltreatment: a metaanalytic review’ Child Abuse and Neglect 24:1127-49; Olds et al 1997 op cit.; Olds et al 1998 op cit.
184
Eckenrode J, Ganzel B, Olds D and Henderson C (2000) ‘Preventing child abuse and neglect with a program of
nurse home visitation: The limiting effects of domestic violence’ Journal of the American Medical Association
284:1385-1391
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TU
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185
Bugental D B, Lin E K, Rainey B, Kotkotovic A and O'Hara N (2002) ‘A cognitive approach to child abuse
prevention’ Journal of Family Psychology 16:243-258.
186
Mondy L & Mondy S (2004) ‘Engaging the community in child protection programmes: the experience of NEWPIN
in Australia’ Child Abuse Review 13(6):433-440
187
Cf work of Prof L Newman of NSW Institute of Psychiatry
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Examples of tertiary prevention interventions include a variety of intensive family
intervention programs. Greater success is reported when professional staff are used
to teach parenting skills, focusing on parent-child interactions in the home.188 Other
interventions target offenders (to sensitise them to the impacts of their behaviour),
non-offending parents (to encourage their support for their children), and support to
children in foster care.
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Various therapeutic interventions have been evaluated, including therapeutic child
care models, individual cognitive behavioural therapy with children, which evaluated
better than child centred therapy in a randomized control trial.189
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The literature on effectiveness of such interventions is, however, limited because
relatively few agencies have attempted to incorporate pre- and post-test comparisons
of impacts on participants. More rigorous evaluations, in which control groups are
used, follow-up assessments are undertaken, and potentially confounding variables
are controlled, are very rare.190 Barriers to quality evaluation include fears by service
providers that findings may be negative and threaten future funding, a perception that
evaluation diverts scarce resources away from service provision, a lack of evaluation
expertise among staff, ethical concerns about issues such as assignment of children
to control rather than treatment groups and the short time frame of many programs,
which means they are unable to undertake long-term follow-up of participants.
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Also according to the CHSD review of the evidence, cognitive behavioural therapy is
effective in reducing trauma among children and parents in cases of confirmed
abuse; therapeutic strategies focusing on improving parent-child interactions in
families where abuse has occurred have promise; and there is clearly a need for
more and better quality evaluations of Australian programs supporting children
exposed to domestic violence.
Factors for success in interventions There are a number of factors for success in these interventions that have relevance
to service collaboration or for their adoption in a primary health care setting. Shonkoff
and Phillips point to five key factors:
(1) individualisation of service delivery; (2) quality of program implementation;
(3) timing, intensity and duration of intervention; (4) provider knowledge, skills
188
Kovacs & Tomison 2003 op cit; Chaffin M, Silovsky J, Funderburk B, Valle L A, Brestan E V, Balachova T et al.
(2004) ‘Parent–child interaction therapy with physically abusive parents: Efficacy for reducing future abuse reports’
Journal of Consulting and Clinical Psychology 72:491– 499.
189
Kovacs & Tomison 2003 op cit; Cohen J A, Deblinger E, Mannarino A P & Steer R A (2004) ‘A Multisite
Randomized Trial for Children With Sexual Abuse–Related PTSD Symptoms.’ Journal of the American Academy of
Child and Adolescent Psychiatry 43:393–402
190
Kovacs & Tomison 2003 op cit.
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and relationship with the family and (5) a family-centred, community based
coordinated orientation.”191
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Shonkoff and Phillips also highlighted the benefits of providing interventions that
focus on both the child and the parents, often delivered in an environment (such as
child care centre) that allows specific attention to the needs of both.
Olds’ finding that even well evaluated interventions cannot reliably be successfully
replicated in a general way, with attention only to the idea behind the model, is also
important. His finding that paraprofessionals delivering a home visiting program
designed to be delivered by nurses did not replicate the same outcomes is a salutary
lesson.192
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The benefits of access to high quality child care may be a case in point. In chapter
One we made the point that disadvantaged children both stood to gain most from
high quality interventions but also stood to lose most when exposed to programs of
compromised quality. There may be an exception to this, based on a notion similar to
Maslow’s hierarchy of needs. Access to a safe child care environment for children at
very high or immediate risk might well provide an immediate preventive gain for those
children. However, in general, the evidence is clear that adherence to program
integrity and quality indicators is especially important for children at risk of poor
developmental outcomes through their family’s poor capacity or dysfunction.
Models applied in primary health care A number of these interventions are amenable to delivery through primary health
care services and, indeed, there are already examples of Australian primary health
care services providing such interventions to Indigenous children. One example is
the Early Years Centre in Nerang (Queensland), funded by the Australian
Government with the service auspiced by the Benevolent Society and due to start
operating later this year.
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From the Benevolent Society website – www.bensoc.org.au
HTU
UTH
The Early Years Centre in Nerang on the Gold Coast will provide families who
have young children with a parenting 'one stop shop' - somewhere they can
access a range of support and services to improve their children's health,
well-being and safety. Families in the local area who have children aged 0-8
years will be able to access:
191
Shonkoff and Phillips 2000 op cit. p 360
192
Olds et al 1997 op cit.
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- health services for children and mothers - including maternal and child
health nurses, breastfeeding support, post-natal clinics, developmental
screening and assessments, and specialist clinics such as immunisations and
paediatrics.
- early childhood care and education - including access to family day care,
coordinated playgroups, a toy library, and programs focusing on areas such
as transition to school.
-family support services - including parenting programs and professional
home visiting for families who need a little extra support.
parenting information, advice and resources covering a broad range of issues
such as child development, behaviour management, parental coping skills,
immunisations and nutrition.
The Early Years Centre will operate from a central 'Hub' in Nerang and will
also provide services from other organisations within the local community. We
will also be working in partnership with a number of local organisations. The
Centre will be operating from November 2007.
In the Indigenous sector, Central Australian Aboriginal Congress was interviewed for
this review and explained that their approach has been to successively build such
services into their model of comprehensive primary health care. This has included
the recruitment of a child development specialist to run the Congress child care
centre, the employment of both clinical psychologists and social workers to work with
both families and young people, the initiation of a nurse home visiting program and
emphasis on a ‘family-centred’ orientation in training of all clinic staff. 193
This last point mirrors a policy commitment made by the NT Department of Health
and Community Services to develop a similar ‘family-centred’ orientation in staff of
the Department’s remote primary health care centres and a new model of care based
on a mix of staff including welfare professionals and para-professionals alongside
community nursing staff and Aboriginal Health Workers.194
An independent evaluation of the Coalition of Aboriginal Agencies “Indigenous
Families Program”, which focussed on its intensive family preservation work with 25
distressed families in Perth, WA, found a benefit ratio of at least 1.5:1.195 The
193
Ah Chee D and Boffa J, personal communication & Boffa J (2000) Discussion Paper on the role of the Congress
Social and Emotional Health Branch. Unpublished paper. Central Australian Aboriginal Congress. Alice Springs.
194
DHCS (Northern Territory Department of Health and Community Services) (2004) Aboriginal Health and Families:
A Five Year Framework for Action. DHCS. Darwin. Available:
http://www.nt.gov.au/health/comm_health/abhealth_strategy/apact/apacttoc.shtml
195
Mooney G and Dzator J (2003) CAA Indigenous Families Program: An Independent Evaluation. Curtin University,
Perth, WA
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Coalition of Aboriginal Agencies includes the Aboriginal Medical Service in Perth,
Derbarl Yerrigan.
‘Little Children are Sacred’ report and response Recommendations and action areas from the recent Little children are sacred
report196 included a number focusing on the role of primary health care to address
‘underlying risk factors, and develop functional communities in which children are
safe.’ In relation to core education and primary health care services the report
recommended:
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That a maternal and child health home visitation service be established in
urban and remote communities as soon as possible;
•
That there be an increased focus on pre-natal and maternity support leading
into early childhood health development for the 0-5 year-old age group; and
•
That PHC provider roles in protecting children from harm be strengthened by:
providing relevant protocols, tools, training and support, including the
development of a multidisciplinary training course for PHC providers.
The report has also recommended targeted services and programs to support
vulnerable and/or maltreated Aboriginal children and their families which are relevant
to a primary health care setting. In particular:
•
That the Aboriginal Medical Services establish family support programs for
Aboriginal children and families in urban and remote settings;
•
The establishment of multi-purpose family centres or “hubs” in remote
communities and regional centres to be a focal point for the provision of a
range of local and visiting programs;
•
Expansion of parenting education and parenting skills training for young
people.
In the 2007 Budget the Australian Government allocated $37.4 million over four years
to establish and evaluate sustained nurse home visiting services in Aboriginal
primary health care settings, which will allow for the assessment of the effectiveness
of a successful intervention in this new context. Specifically, this is aimed at providing
regular nurse home visiting services to all women pregnant with an Indigenous child
196
Anderson and Wild 2007 op cit.
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in targeted outer regional and remote areas until the child reaches two years of age,
and child and family support for at-risk Indigenous children aged 2-8 years.197
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In addition, the 2007 Budget includes $13.8 million over four years to expand
playgroup services for Indigenous families and, most significantly, $23.5 million over
four years for improved access to child care and early childhood services, including
establishing 20 new child care service hubs in rural and remote communities198.The
new Hubs aim to provide integrated early childhood services and complement the
early childhood health measure outlined in of the report. Hubs will provide child care
services as the core and will link with other local children’s and family services to
improve integration of service delivery in the community. For example, a Hub may
facilitate a parental education program on site and include a daily nutrition program
as part of the child care service.
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The Northern Territory Government has also responded with a number of
commitments, and in particular the allocation of $9.6m for the establishment of family
centres in remote communities, improved antenatal care and maternal health
programs and child care and early education services199.
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Note that another relevant reference point is the national Social and Emotional Well
Being Framework 2004-2009.200 One of the frameworks key result areas is
Strengthening families to raise healthy, resilient infants, children and young people.
The rationale for this is based on evidence that positive mental health outcomes in
adults are, to a large extent, determined by health influences and experiences in
early childhood.201 Most services however, are aimed at adults. The report
recommends support to mothers during pregnancy and immediately following birth in
order to contribute to positive learning outcomes and to children being able to meet
age-appropriate milestones and to engage in healthy social and family relationships.
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Opportunities for a primary health care contribution There would appear to be a number of opportunities for primary health care services
to embrace a stronger role in family and child welfare. Possibilities include:
197
Australian Government (2007) Budget 2007-08. Available: http://www.aph.gov.au/budget/200708/bp2/html/expense-16.htm
198
ibid
199
Northern Territory Government (2007) Closing the Gap of Indigenous Disadvantage: Generational Plan of Action.
Available: http://www.action.nt.gov.au/fact_sheets/health.shtml
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200
Social Health Reference Group for National Aboriginal and Torres Strait Islander Health Council and National
Mental Health Working Group (2004) Social and Emotional Wellbeing Framework: a National Strategic Framework
for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Well Being. Available:
http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/8E8CE65B4FD36C6DCA25722B008342B9/$File/well
being.pdf
201
Mrazek P J & Haggerty R J (1994) Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention
Research. National Academy Press. Washington DC.
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•
The provision of family welfare services in settings that families access and which
do not carry the stigma of many welfare, especially child protection sites. The
example of child care services is often raised and the provision of relevant
primary health care services in child care services is one option. Equally health
care services are normal places for families to attend. A range of the
interventions covered in this chapter can be provided through primary health care
services, for example accompanying maternal and infant clinics or specialist
paediatric outreach clinics.
•
Nurse home visiting is another example of a service with multiple service
objectives that can be based in primary health care services. It is also worth
exploring the possibility of primary health care as a base for parenting
interventions, including Triple P type behavioural oriented programs or
therapeutic models targeting attachment and trauma issues in parents and
children who have been exposed to abuse.
•
The participation of primary health care services in a number of family preservation
programs that work with families where children are at high risk of statutory action has
already been trialed in the Aboriginal sector in Australia202, as part of the work of the
Coalition of Aboriginal Agencies referred to above.
•
The role of primary health care in the provision of community mental health and
alcohol and drug services is also of obvious importance in building family welfare
and resilience and again could be combined with other child and family service
interventions.
•
The role of primary health care services in the organizing of screening and
organizing follow up for a range of developmental delay related services.
•
develop governance and partnership level links with local education and child
welfare organisations.
202
Mooney and Dzator 2003 op cit
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CHAPTER SUMMARY: HEALTH AND WELFARE
1. Child abuse and neglect have health consequences, including effects on
cognitive and educational attainment, a life course risk of chronic disease, and social
and behavioural development.
2. There are important questions about the capacity of child protections systems
focused on statutory processes to address the broader needs of children and
families.
3. Effective family support interventions require action on the part of primary
health care services, beyond their responsibility to participate in notification and
investigation processes.
4. Possible levels of intervention in child and family welfare:
•
Primary level interventions aimed at all children and their parents and include
parenting programs, child education programs and welfare reform.
•
Secondary level interventions are aimed at families at risk through home visiting
or parent training.
•
Tertiary level interventions involves minimising harm to children in cases of
confirmed abuse, including therapeutic support, education or counseling for
parents, and support for foster parents or the family of origin.
5. Factors for success in interventions (from Shonkoff and Philips 2000 p360):
•
individualisation of service delivery;
•
quality of program implementation;
•
timing, intensity and duration of intervention;
•
provider knowledge, skills and relationship with the family; and
•
a family-centred, community based coordinated orientation.
6. Opportunities for primary health care services
•
provision of family welfare services in non-stigmatized settings;
•
nurse home visiting;
•
participation in family support programs;
•
provision of community mental health and alcohol and drug services; and
•
organisation of screening and follow up for developmental delay related services.
•
develop governance and partnership level links with local education and child
welfare organisations.
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5.
Implications for Primary Health Care In the first four Chapters we argued that a child development framework provides the
best way to understand the compelling links between the life course health outcomes
that start in the early years, education and child and family welfare. We have looked
in detail at the evidence about how health is related to education and to welfare and
at the experience of service models in each area.
In this Chapter it is time to examine the implications of this analysis for the practice of
family-centred primary health care. In the next Chapter we will look at how good
practice can be “scaled up” to become a system wide intervention.
Note that in this Chapter we are not introducing new evidence, but reviewing and
summarizing the evidence put forward in Chapters Two, Three and Four. The
lessons we have drawn from the material reviewed in these Chapters have
implications for family-centred practice. This includes lessons for service design, the
scope of practice defined as fitting within primary health care, the way in which
health, education and welfare services relate to each other, and about whether there
are altogether new models of service that are needed. There are also lessons for the
individual professional practice of health and other professionals, for basic and
postgraduate training, and for the skills we value within our services.
As noted in Chapter One, these lessons apply to clinical practice across the life
course, including for the management of chronic disease in adulthood. However this
review focuses on the implications for child development, when life course health
trajectories are set.
In this Chapter we will provide a summary of the conclusions of Chapters One to
Four about service redesign and professional practice. We will consider two possible
models of implementing family-centred primary health care, based on different
assumptions about the degree of institutional reform that is possible.
First, assuming an ‘incremental’ change model, what would primary health care
services do better or do differently given the evidence outlined in the previous three
chapters?
Second, turning to a more radical integration of relevant services into a single
broader family-centred service, what would such a model look like and how and
where could it be established or trialed?
These two approaches are not, of course, mutually exclusive. We would argue that
strengthening and extending services in the light of the evidence about child
development an important part of comprehensive primary health care. We would also
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suggest that it is important to trial (and, if successful following evaluation, extend) a
more radical new model to address Indigenous child disadvantage.
This Chapter is focussed on how to make change in the real world.
Lessons for family‐centred primary health care During the course of Chapters One to Four we drew a number of conclusions with
significance for primary health care practice, most fundamentally the importance of
the realisation that health, education and welfare share a common interest in child
development. In each discipline we found reference to the same foundational work
on the physiological, psychological and cognitive consequences of neural pathway
development; the same evidence on the importance of close infant attachment to a
consistent parent figure; and we found the same concern about the intergenerational
implications of not attending to this evidence.
Primary health care services in Indigenous communities in Australia are hugely
varied, in terms of provider, location, degree of community engagement, clinical
reach, staffing and size.
Providers range from the hundred or so community-controlled Aboriginal health
services, independently incorporated and funded largely through the Australian
Government, to the many State or Territory government run clinics especially in
remote areas, to general practitioners whether in private practice or employed by
local government agencies. Some services are located in cities, others in regional
centres and others may have a dispersed model of a number of separate clinics over
huge areas of remote Australia. Some services are large (some of the larger
community-controlled services employ well over a hundred staff) with
multidisciplinary teams of doctors, nurses, Aboriginal Health Workers and other
health and policy staff; some have a small team or even consist of a single individual.
This diversity – and the diversity of the populations they serve – makes it impossible
to be prescriptive about exactly what a service should provide and how.
Nevertheless, Chapters One to Four suggest that health care services are vitally
interested in the provision, not only of services they have regarded as their core but
also of a wider range of other services core from a wider, child development
perspective. In some cases, other sectors will be best placed to provide those
services. In some cases health services will be best placed. It is no longer possible,
however, for primary health care services to be disinterested in their provision.
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Core services for child development We turn now to recapitulate that range of evidence based services that constitute the
wider range of core child development interventions, based on the conclusions of the
previous Chapters.
These are summarised in the following table, which gives a sense of how the three
different sectors – health, education, and welfare – look at the same issues of child
development through three different prisms of understanding, and how their services
are complementary.
Key areas for intervention
Primary Health
Care
Predominantly focused
on women before and
during pregnancy
•
Tobacco
•
Alcohol
•
Sexual health
•
Antenatal care
•
Family planning
•
Nutrition and folate
•
Social support and
education
Education
School readiness
programs
Primary level
interventions
•
•
parent information and
education programs
•
child education
programs
•
welfare reform.
Pre-schools and day
care programs with preschool education
curriculum and
structured playgroups
Family support and
parenting programs
Early intervention
programs that incorporate
both the above elements
Predominantly focused
on the child after birth
•
Breastfeeding and
nutrition
•
Nutrition
•
Immunisation
Home visiting
•
Child and
Family Welfare
Nursing staff visiting
pregnant women and
young families at home
can deliver positive
results. However,
design integrity and
sustained programs are
critical for success.
IMPLICATIONS FOR PRIMARY HEALTH CARE
Secondary level
interventions
•
home visiting or parent
training
•
access to quality child
care and playgroup
programs
•
combinations of
interventions targeting
both parent and child.
Tertiary level
interventions
•
therapeutic
interventions with
children, parents or
both
•
targeted education or
counselling for parents
•
support for foster
parents or the family of
origin.
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Role of PHC
Primary Health
Care
Beyond mother and child
(working with the reality
of Aboriginal family
structures)
Education
Nutrition
Hearing health
Provision of family
welfare services in
universally accessed,
non-stigmatized settings
Developmental screening
Validating Indigenous
views on child health
Beyond standard clinical
interventions
Primary health care
services as a possible
site for early learning
interventions
Sustained nurse home
visiting
Participation in family
support programs
Beyond the clinic setting
(home visiting and
outreach services)
Provision of community
mental health and alcohol
and drug services
Working in schools
Organisation of screening
and follow up for
developmental delay
related services
Working with child
protection agencies
Principles for successful intervention
Child and
Family Welfare
Local community
engagement, including
employment
A commitment to a focus
on child and maternal
health
A professional
multidisciplinary
workforce supported with
training
Parental involvement
Content that focuses on
developmental needs and
prepares children for
school
Well-trained staff with low
client to staff ratios
Accessibility (home or
centre-based)
Proper resourcing to
enable sustained effort
Local and specific to the
needs of the community
Good clinical and
management systems
Primary health care
programs work integrally
with interventions from
outside the PHC sector
Collaboration with other
local services
Individualisation of
service delivery
Quality of program
implementation;
Timing, intensity and
duration of intervention;
Provider knowledge,
skills and relationship
with the family
A family-centred,
community based
coordinated orientation
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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Best Practice: primary health care professional practice Moving beyond the question of the scope of family-centred primary health care
services, there are also a number of implications of this evidence for the practice of
professional staff.
These practice skills are, as noted, relevant to the provision of effective familycentred practice across all ages, as well as having a specific salience for the early
years. Implementing them is likely to be a matter driven by local capacity and
priorities – indeed many of these service extensions require a high degree of skills
not specifically provided in the health professions and of engagement with the local
community.
•
Beyond mother and child. Services and professionals within them recognise
and work with the reality of Aboriginal family structures to recognise and
engage the range of carers, not just the mother. This may include
grandmothers, aunts and the older siblings of young children, as well as very
importantly male care givers, especially fathers.
•
Validating Indigenous views on child health. This may include adding to the
standard child and maternal health care delivery team to include significant
Aboriginal community members (for example, grandmothers and others with
traditional responsibility for birthing and child-rearing).
•
Beyond standard clinical interventions. For example, by providing books,
baby massage, and adding their own skills in child and maternal health to
other teams, eg at playgroup, child care centre or pre-school.
•
Beyond the clinic setting. Providing services outside the clinic, particularly
regular home visiting but also including providing services in collaboration
with other agencies such well as outreach to prisons, schools, childcare and
pre-schools and play groups.
•
Working in schools. As well as providing the usual menu of health screening
in local schools and pre-schools, including immunisations and hearing
assessments, primary health care services to provide advice on hearing
health to schools themselves (including input into acoustic classroom design)
as well as adolescent health programs and assistance to young mothers
through high schools.
•
Working with child protection agencies. Includes going beyond the carrying
out of statutory obligations of notifying child protection agencies when
necessary, to identifying and working with children and families at risk before
any direct evidence of abuse or neglect is apparent. It also means staying
involved with families that are the subject of child protection investigation and
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action, for example by providing a range of clinical and non-clinical support to
the child and the non-offending parent.
A new model: child development centres On the evidence we have discussed from Chapters One to Four, there is strong
support for primary health care services to:
•
optimise their own core maternal and child health practice;
•
become aware and involved in the wider range of service needs that
constitute what we have called the child development field;
•
be prepared to get directly involved in those when needed; and
•
encourage their individual staff to adopt more family-centred personal
professional practice.
This would improve the effectiveness of health services, even without any change to
the structure of the current child health, education and welfare silos, just through the
more effective cooperation and individual professional practice that would arise.
However, is this enough? Given the success of more thoroughly integrated early
childhood interventions elsewhere, it is arguable that there is a strong case for a trial
of such services in a number of Indigenous communities across Australia.
Background As we have seen, integrated early childhood interventions for disadvantaged families
have been a feature of overseas health and social policy since the 1960s, particularly
in the United States with the Head Start program and its derivatives such as the
United Kingdom’s Sure Start program.
More recently there have been a number of policy frameworks that have encouraged
a similar approach in Australia, including Families NSW and Best Start in Western
Australia and Victoria, the Early Years Strategy in Queensland, Early Childhood
Development Centres in South Australia, and Early Years Integrated Services in
Tasmania. Many of these are still at the stage of policy or early implementation, and
evaluations though built into the models are not yet available.
It remains true that, despite these policy frameworks and the establishment of a few
comprehensive integrated early childhood services (for example, Café Enfield in
South Australia) integrated early childhood services are not yet an established part of
the normal service mix delivered by governments in Australia.
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Partly this may be because the social contract in mainstream Australia over the last
thirty years or more has seen the basic infrastructure of education, health, child care
and social services become a normal expectation of what Australian governments
provide their citizens. Universal, free access to health care is an important difference
to the United States system for example. Under these conditions, the pressure to
provide a targeted intervention for disadvantaged families, charged with
compensating for basic service gaps, has not gained the same momentum and may,
paradoxically, have inhibited the same level of innovation in the development of truly
integrated service delivery.
It is important to note that this is not due to the ‘failure’ of any individual program or
professional group or indeed Government, but is the result of the particular social and
political contexts in which early childhood care is embedded in Australia. There is
also no doubt that complex – not to say sometimes confused – jurisdictional
responsibilities have contributed to the delays in taking a successfully integrated
approach to early childhood services.
However, the conditions that obtain in mainstream Australia have not been mirrored
in Indigenous communities, which despite improvements, continue to be marked by
poorer access to health services relative to need, and a service infrastructure
(including vital services such as schools, sanitation, housing etc) that is often
teetering on the point of dysfunction, if not actually dysfunctional. This situation is
much more analogous to that which gave rise to the kind of family-centred early
childhood interventions that have proven successful in the United States.
While the Australian primary health care, education and welfare sectors should
continue to pursue their own improvements, the evidence and service models
examined in this review suggest that the multiple problems faced by many
disadvantaged Indigenous families means that a more radical model is warranted.
This would involve the setting up on a trial basis of a number of child development
centres, which after evaluation could be extended across Indigenous Australia.
Child development centres: key concepts This idea of integrated and holistic early childhood centres is consistent with key
recent documents. As we have seen, the Northern Territory Government’s Little
Children are Sacred report recommends the establishment multi-purpose family
centres203, and the Australian Government’s Indigenous Child Care Services Plan204
(released during the preparation of this report) supports the development of holistic
services for Indigenous children, including the development of early childhood
service delivery models that promote integration or coordination with other services
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Anderson and Wild 2007 op cit p 26
204
Australian Government 2007b op cit; Australian Government 2007c op cit.
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and where appropriate, integrating or co-locating other government family support
services within a child care service hub.
In this section, we want to take this further to ask: what would such an integrated
model based on early childhood development concepts model look like?
First, local conditions, strengths, priorities and skills are crucial in shaping the nature
of such centres because intervening in the health, education and welfare of children
requires the maximum possible engagement of the community.
At the same time these interventions must be based on principles and practices that
the evidence can support. For example, one common element to emerge from our
review of the evidence in each of the Chapters is the crucial importance of qualified,
experienced professional staff.
This transformative model is based on combining services from the different sectors
that we have outlined in Chapters Two to Four – health, education and welfare – into
an integrated service form. These integrated child development centres would
combine the relevant budgets and workforces into a single service that responds to
both the presenting problems and the underlying factors related to child development
and well being. They might include many of the interventions outlined above, for
example:
•
Primary health care – maternal and child health interventions, including
interventions in pregnancy, immunisation, nutrition, sexual health and family
planning, alcohol, tobacco and other drugs, and social and emotional wellbeing.
•
Education – school readiness programs, structured playgroups, parenting
skills, preschools and quality child care.
•
Child and family welfare – linking all non-statutory functions, for example
therapeutic, early intervention and family support.
The key concepts behind this model would include:
•
A focus on outcomes in health, education and welfare for children up to eight
years old;
•
Involvement of family and community and availability to all families and
community members;
•
Being based in resilient, robust organisations that are well-governed and
responsive to local need (whether primary health care service, school, or
other organisation) with other services being ‘scaffolded’ onto what they
already provide;
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•
A sector-wide approach, involving funds pooling from relevant agencies on a
transparent and consistent basis;
•
Professional management and skilled staff with a combination of generalist
and specialist knowledge, and employing local community members as a
priority;
•
Well defined structures for community engagement;
•
Strong local support for each centre including agreements with other local
service providers; and
•
Evaluation to be built in to the service, with the recognition that many benefits
may take some years to emerge and that full cost-benefit analyses are only
possible with sustained programs.
Such an approach can also expect to face a number of challenges. We would
predict, for example, that some attention will need to be given to breaking down the
established professional ‘silos’ of health, education and welfare to ensure that they
work together (at both an organisational and an individual level).
Funds pooling between different areas and levels of Government has also proved in
some cases to be complex and sometimes slow, and the widely varying ranges of
services available in each locality would also need to be addressed (see ‘Mapping
existing services and filling gaps’ in Chapter 6 below).
Site selection and funding for trials Site selection for trials would need to take all the above into account, and we would
recommend a minimum of six sites being selected in a variety of organisational and
geographical contexts (for example, one or two sites each in remote communities,
regional centres, and metropolitan areas and the deliberate selection of different
service types to host the centres). Trials would need to be for a minimum three years,
with a commitment to continue funds pooling at the end of this period pending the
results of evaluation. Funding would be needed to plan, develop, establish and
evaluate pilot services and might well be needed to supplement existing budgets for
existing service gaps. However, these centres should not be dependent on greater
funding than would be derived from the combination of standard, adequate funding
for each of the service components.
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CHAPTER SUMMARY: IMPLICATIONS FOR PRIMARY HEALTH CARE
1. Strong common interests unite the fields of child health, education and welfare,
which point to a set of common service imperatives.
2. The development of family-centred primary health care should be based on
maintaining a clear focus on the development of the child as the key to building
health and resilience for life in the early years.
3. Direct implications for the suite of services offered by primary health care
services and primary health care professionals include:
•
optimising their own core maternal and child health practice;
•
becoming aware and involved in the wider range of service needs that constitute
what we have called the child development field;
•
being prepared to get directly involved in those when needed; and
•
encouraging their individual staff to adopt more family-centred personal
professional practice
4. Primary health care service reform can be pursued as a gradual process,
through service development and better coordination between health, education and
welfare services.
5. There is a strong argument for piloting a radical model of service integration
through the creation of a number of child development centres, providing a
range of all these service elements from within one entity
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6.
Scale Up and Sustainability In Chapter Five we considered the implications of the evidence reviewed for familycentred primary health care. We developed two models: the first based on
developing family-centred practice within primary health care without any change to
the current service silos in health, education and welfare; and the second based on
piloting a number of integrated child development centres.
The purpose of this last Chapter is to consider the issue of how either approach can
be developed as a reform process across the different jurisdictions and settings
where Indigenous families live and in all services, not just those led by an exceptional
clinician, manager or community leader.
Closely linked to this is the question of sustainability. Too often in Indigenous service
delivery we fail to implement on a wider scale the lessons learned from small scale
examples of excellent practice. Equally often we fail to sustain excellent practice and
innovative services flounder because of workforce or governance crises.
It is, of course, essential for building successful systems to have the flexibility to
engage with local diversity without losing the essential elements. However, it is
important to look beyond the importance of the individual and the local. We need to
ask, what are some of the underlying principles for designing, implementing and
sustaining successful health intervention programs?
Principles of sustainability Models from other developed countries Service sustainability is a challenge that is engaging governments around Australia
and across the developed world.
The Australian Government has attempted system wide change in early childhood
through both policy (Australian Government leadership of the National Agenda for
Early Childhood) and through funding programs (Communities for Children). There
are also a number of State programs as well including Families NSW and Best Start
in Victoria.
Two recent reviews cover a range of Government initiatives in Australia and in the
UK and North America.205 Common lessons from these reviews included:
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•
The importance of recognising that skilled staff and low child:staff ratios are
essential to program success and that there is significant danger of diluting
program integrity in replicating models evaluated well elsewhere;
•
Effective community engagement is important to ensure community
acceptance of reform and new service priorities and models and that
governance of integrated models is helped if community and client voices are
included in governance structures, with effective support for the development
of the individuals who take on these onerous roles;
•
Understanding that these first two objectives especially mean that it is
essential to plan to sustain support through the necessarily lengthy time
sound program development requires;
•
Building innovative integrated models onto strong pre-existing infrastructure
has multiple advantages. One consideration, highlighted in Valentine et al’s
commentary on the UK Sure Start program, is the asymmetry in which kinds
of service have the greatest coverage of the population at different ages.
Health services tend to be the fastest and most effective at establishing
integrated programs for the very young, because all families access them
around birth and early in infancy. Schools have a similar advantage later in
childhood. Sure Start found health services also spent less time on
negotiating the complexity of new arrangements.206
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•
Accepting that professional, disciplinary and service perspectives and
priorities will differ, despite common objectives and that, while in theory
integration should promote efficiency, integration will involve effort, time,
tension and sometimes managing conflict;
•
While evaluation is essential to service implementation, fine tuning and
eventually judging value for money, there are traps in putting too much
emphasis on evaluation. These can include data capture demands that are so
high they prejudice service provision; forcing innovative models to
oversimplify their performance indicators so that they can prove an outcome,
even if these are not themselves profound; or being held up to criticism by
people hostile to the project because not enough time was allowed for the
new model to run its course, or because the evaluation strategy is not
sophisticated enough to capture what is actually happening “on the ground.”
206
Valentine et al 2007 op cit p9 & p44; National Evaluation of Sure Start Team (2005), Early Impacts of Sure Start
Local Programmes on Children and Families: National Evaluation Report, University of London
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•
Finally “policy matters”: top-down support from Government can be as
important as local engagement to support innovative models to weather the
inevitable tensions and problems that real service reform will encounter.
Models from international development In the field of international development, the theory and practice of sustainable
development is highly developed and an important – if not the most important –
consideration in designing and developing new services. We turn now to examine
some of the lessons from this field, which also have a number of useful lessons for
interventions in Indigenous health within Australia.
The concept of sustainable development was first brought into general use through
the United Nations’ Report of the World Commission on Environment in 1987, where
it was defined as "development which meets the needs of the present without
compromising the ability of future generations to meet their own needs”207.
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The concept of sustainable development has been elaborated to include four main
areas: economic development, social development, environmental protection, and
cultural diversity, the last of these being seen “not simply in terms of economic
growth, but also as a means to achieve a more satisfactory intellectual, emotional,
moral and spiritual existence"208.
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The concept of sustainable development has also been applied to international
development, such that it is generally accepted that all development assistance,
apart from temporary emergency and humanitarian relief efforts, should be designed
and implemented with the aim of achieving sustainable benefits as a way of reducing
the costs of implementation, reducing dependence, and ensuring their longevity.
All these factors are applicable to innovation in Indigenous health and social policy
and the following principles for sustainable development should be a key part of
implementing a family-centred primary health care strategy for Indigenous
communities209.
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1. Participation and ownership. Community members, both men and women,
should genuinely participate in design and implementation, and their
initiatives and demands should be incorporated into the project. The
207
United Nations Department of Economic and Social Affairs Report of the World Commission on Environment and
Development. Available: http://www.un.org/documents/ga/res/42/ares42-187.htm
U
U
208
UNESCO (United Nations Education Scientific & Cultural Organisation) (2001) Universal Declaration on Cultural
Diversity. Available: http://unesdoc.unesco.org/images/0012/001271/127160m.pdf
U
209
U
AUSAID (Australian Agency for International Development) (2000) Lessons learnt from development projects.
U
AUSAID. Canberra.
U
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community should also be involved in monitoring the project and periodically
evaluating it for results.
2. Capacity building and training. Employing and training community members
as part of the program should begin from the start of any project and continue
throughout with the aim of both motivating and transferring skills.
3. Financial. Projects should have secure, long term funding. However,
identifying other sources of funding should be encouraged, for example,
through partnerships with other non-Government or private organisations.
4. Management and organisation. Programs should be integrated or added to
local structures rather than established as new or parallel structures.
5. Social, gender and culture. The introduction of new ideas, technologies and
skills requires an understanding of local decision-making systems, gender
divisions and cultural preferences. These cannot be assumed to be the same
across Indigenous Australia, or even from community to community within a
region.
6. External political and economic factors. Projects should not be too
complicated or ambitious.
7. Realistic duration. Short projects may be inadequate for solving entrenched
problems such as the intergenerational and complex nature of child
disadvantage in many Indigenous communities, particularly when behavioural
and institutional changes are intended.
‘Scale up’: a system‐wide approach to change Bearing the lessons for sustainable development from both the developed and
developing world in mind, how then do we progress making system-wide change of
the type we have described in Chapter Five? There are a number of key strategies.
The following list cannot be exhaustive – much will depend on the actual process of
implementation – but these are the main areas where action is required.
Mapping existing services and filling gaps The extent to which Indigenous primary health care services are already delivering
on interventions suggested by the evidence is highly variable. A first step, then,
would be to survey the extent to which these services are already doing this with a
view to identifying deficits and, for services within their core health responsibilities,
addressing them. This process could usefully be built onto a quality improvement
model, whereby services identifying gaps are supported and as possible resourced)
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to fill those gaps to an agreed plan, rather than a model of surveying all health
services with a view to possible future resourcing. This may mean a process of
working with service providers (Government and community-controlled) on site
selection and prioritisation.
A process of developing accreditation for Aboriginal primary health care services in
meeting the core service requirements of maternal and child health and early
childhood development is now underway as a result of a Australian Government
2007 Budget initiative. This could provide a useful vehicle.
Workforce Strengthening and extending primary health care services to take account of the
evidence in child development will depend to a great extent on the availability of a
well-trained, stable and confident workforce that prioritises these services. Priority
issues to be addressed would include:
•
training in the child development approach for primary health care staff and
managers;
•
referral networks and protocols, including information sessions for health
professionals on both mandatory reporting in each jurisdiction and the range
of other education and welfare services available to complement and support
their wider role in these areas and to ensure practice meets those standards;
•
a renewed effort to reform professional and training structures for those
segments of the workforce most critically undersupplied, especially in outer
metropolitan, regional and remote areas (such as the various allied health
professions); and
•
recruitment and retention of staff, including accommodation for staff in remote
areas.
Consideration should be given immediately to how the funds recently made available
through the Australian Government’s 2007 Family-Centred Primary Health Care
budget initiative can be deployed to address the greatest deficits against the priorities
identified in this review. These include, for example, child development experts, early
childhood educators, speech pathologists and social workers. This could be pursued
through the survey process suggested above (‘Mapping existing services and filling
gaps’).
As a part of the planning to implement the budget initiative, it would also be
warranted to budget for the facilitation and planning processes at service level for
staff to redesign ways of working together, allowing for the tensions that have been
observed in reviews of other such models.
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Prioritising child development research Development of best practice requires a solid evidence base. In order to develop this,
dedicated research resources need to be made available. Given the importance of a
child development approach, the Australian Government should liaise with the
National Health and Medical Research Council (NHMRC) regarding the possibility of
having a component of the 5% funding quarantined for Aboriginal health research
channelled specifically into these areas.
Standards setting A number of guidelines for health care service delivery have already been published
by the NHMRC. In order to promote a common approach to family-centred primary
health care and especially maternal and child health, the Australian Government
could sponsor a process for using this child development research advocated to
articulate the core services for addressing these within the current evidence through
to NHMRC adoption. This could then be expanded to include ‘service extensions’
such as those outlined in Chapter Five. The process already underway to seek
NHMRC endorsement of universal Antenatal Guidelines for Australia is both a step
toward this and potentially a useful start on which further work could be
commissioned.
Changing expectations There are (often unspoken) assumptions and institutional barriers to a focussed effort
on Indigenous child development perspective. These include, for example, the
strength of the three separate approaches and workforces in health, education and
welfare, or the belief that failure is built into the system and that disadvantaged
people cannot be privileged with high quality services. Breaking down these
assumptions and barriers – and fostering a realistic view of what can be achieved
based on the evidence – is an important baseline task. The work of Chris Sarra,
headmaster at Cherbourg between 1998 and 2004, in which he challenged the
students, the school and the parents of this rural Aboriginal community to expect
academic outcomes equivalent to other Queensland schools makes this point
strongly in the education sector.210
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We suggest that there a number of critical organisations who, if they agree to a
common public stance on these issues can contribute to a much-needed shift in
public perception about Indigenous child development. These would include both
professional bodies, service provider organisations, sectoral organisations from
education and welfare and, importantly Governments.
210
Sarra C (2005) “Armed for success” Griffith Review 11: 187-194
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Policy and community engagement As noted, reviews of previous attempts to pursue sectoral integration require both
leadership from Governments and serious engagement with local communities. The
Australian Government has a key role to play in both of these objectives. Using this
review and a number of other key pieces of work commissioned over the last few
years, the Australian Government can play a leadership role in articulating a new
policy approach with jurisdictions, for example through the new Child Health and
Wellbeing Subcommittee of the Australian Health Ministers’ Advisory Council, and
with the Aboriginal community controlled health services organisations.
Planning for the implementation of the budget initiative should also include the
allocation of resources for the community engagement processes that will be
required at key sites, especially the proposed trial child development sites if that
model is supported.
Evaluation strategy Deciding an evaluation strategy at the outset is a key standard of good practice in
program design. The lessons drawn from reviews of similar programs, however, does
offer a number of salient lessons about the need to plan this strategy in a realistic
way so as not to overburden services with data capture responsibilities; to put
significant effort and consult experts in child development fields in the development
of evaluation objectives and methods; and to allow sufficient time for results to be
delivered before they are evaluated.
Next steps: child development centres Strengthening and extending primary health care services on the basis of the
evidence is a challenge which, although not without its difficulties, is within the realm
of normal practice for health services. This increases in challenge and complexity
when it is combined with the creation of new service structures that will require health
professionals to work directly with education and welfare professionals. It involves a
much greater degree of “going into the unknown.” The following summarise some
additional matters worthy of consideration if this proposal is supported.
Resourcing the model and sustaining other services Coming to agreements – both at the agency and the local level – about funding
models for a trial child development centre is likely to be a complex matter. Key
issues here include:
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•
ensuring the continued sustainability of other services – where some aspect
of a local service is to be absorbed into the child development centre, the
services residual programs need to continue to be viable;
•
maintenance of effort in non-trial sites with the ‘incremental’ agenda of
strengthening and extending primary health care services; and
•
providing adequate sustained funding to resource the centre, and a structure
for managing and distributing this at the local level.
That said, it is important that pilot child development centres are provided additional
funding only for establishment and evaluation costs, service deficits against normal
expectations and to ensure the viability of both the new entity and any residual
service “left behind” in a parent service. It would not be a valid pilot to assess the
effectiveness of a new integrated model, if these were the best funded services. We
would then be assessing the impact of additional funding, not new approaches.
Workforce Once again, workforce is a critical area to be addressed. In setting up new models of
service delivery, it is particularly important to train and orient staff into the new model
especially given its multidisciplinary nature. Other issues may include Industrial and
pay issues; accommodation for staff and incentives for them to reside in remote
areas; importance of a local workforce as champions of the service; sourcing of early
childhood expertise and leadership.
Community engagement Within the parameters of the trial program, engagement with the local community and
its services at all levels, and from the earliest moments of the project, is critical.
Research and Evaluation As we have seen, high quality evidence for broad-scale interventions in early
childhood development is scarce within Australia. It is critical that any trial child
development centres are evaluated to a high standard, with close collaboration with
the local Aboriginal community. Important issues to be considered include:
•
defining the outcomes to be measured and the indicators with which to
measure them before the onset of the intervention;
•
providing adequate resourcing for evaluations up front but, as noted, avoiding
over elaborating the evaluation so that too much of the initiative’s costs are
taken up on evaluation;
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•
measuring organisational issues such as workforce, funds flow monitoring,
information management, and governance, as well as child and family health
and well being improvements;
•
ensuring community perceptions and feedback are a key part of the
evaluation;
•
ensuring comparisons, including of a qualitative nature, between the trial sites
are possible in order to identify the key factors for success; and
•
comparing trial sites with controls.
Site selection for trials As noted in Chapter Five, site selection for trials would need to take all of the above
matters into account. We would recommend a minimum of six sites being selected in
a variety of organisational and geographical contexts (for example, one or two sites
each in remote communities, regional centres, and metropolitan areas and centres
based in clinics, schools, family and early childhood services.)
Trial duration For the reasons outlined above, it is important that any trials would need to be for a
minimum of three years, with a commitment to continue funds pooling at the end of
this period pending the results of evaluation.
CHAPTER SUMMARY: SCALE UP AND SUSTAINABILITY
1. Key areas for action in preparing for implementation – for both the more gradual
and integration pilots strategies – include:
•
a baseline survey of practice, based on a “survey and fix” approach, where issues
are addressed as they are identified with services;
•
workforce development, at a planning level, a policy reform level and with
resourcing from the 2007 budget initiative both to high priority professional groups
identified in this review and to planning and facilitating change at service level;
•
research and standard setting activity in indigenous child development, in
collaboration with the NHMRC;
•
policy leadership and community engagement; and
•
a sophisticated approach to evaluation design, drawing on expertise from the
other key child development sectors – education and welfare.
2. Subject to the idea being supported, site selection for trials of new child
development centres would need to take all of the above matters into account
with a minimum of six sites being selected, and a commitment to continue
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funds
pooling
pending the results of evaluation.
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