Tackling childhood health inequalities

It‘s not rocket science. We know that good physical health in childhood is important in its own right and also increases the chances of good physical health throughout life. And we know that a healthy diet, physical activity and a healthy environment are three cornerstones of children’s physical health. However, we also know that access to these three cornerstones differs by social class, ethnicity and sometimes gender. For instance:

So we know that the UK needs to level up when it comes to health. Physical health inequalities start young – with a higher risk of developing chronic conditions in childhood, for example, more common in children living in deprived areas. 

So, how can we ensure these three cornerstones of children’s physical health are available to all children in the UK - so that wherever they live and whatever their background, they will have access to a healthy diet, physical activity and a healthy environment. What policies are needed?

There’s much that could be done and it would be easy to suggest a long list of policies. However, we suspect that, for decision makers, whether at the heart of government, or elsewhere in the economy and society, less is usually more.

That’s why we propose three core policy priorities:

Health in all policies

For too long it has been assumed that the NHS and Department of Health are responsible for health in the UK. However, as former Chief Executive of the NHS, Sir Nigel Crisp set out eloquently in the title of his 2020 book, Health is made at home, hospitals are for repairs. The NHS is first and foremost a medical treatment service. With honourable exceptions such as vaccination programmes and, more recently, social prescribing, most of its time is spent treating illness rather than preventing it, in responding to poor health rather than creating good health. By the time most children need diagnosis and treatment from the NHS, health inequalities will already be firmly entrenched and may well be the reason they need medical help.

In practice many other government departments have an important potential contribution to make to children’s physical health. These include:· 

  • Education (with both curriculum and inspection arrangements potentially influencing health, from the important early years provision through to the primary and secondary school years) 
  • Environment and Food (important in encouraging healthy environments, physical activity and healthy diets)
  • Housing, Communities and Local Government (with quality and stability of housing important for children’s health and local government relevant in a number of ways, not least its Public Health responsibilities)
  • Media and Sport (the impact of social media on young people’s mental health is being increasingly researched but much less, as yet, the impact of sedentary screen time on physical health; and Sport England research has identified how much more needs to be done to encourage and level up access to different sports).

From this perspective the NHS and Department of Health currently have only a modest role to play in children’s physical health. It is the other major government departments which have greater potential influence.

When it comes to children’s health, therefore, there needs to be a joined up cross government approach. Unless and until this is achieved, children’s physical health will continue to be at risk.

The same point applies at Local Authority level, where Health in all Policies is now being attempted in some areas, with guidance from the Local Government Association, but needs to be significantly extended and expanded.

HealthPLUS

Knowing that something is good for us and acting on that knowledge are two different things, including for children and the parents and teachers who influence them. This means it isn’t enough to provide information on the health benefits of physical activity or a healthy diet or even to raise their profile within the curriculum (welcome as that would be). Any policy needs to be grounded in an understanding of what encourages children’s physical activity and what encourages them (and their parents) to pursue healthy diets and how these motivators potentially vary by age, gender, social class and ethnic origin, as a one size fits all approach may well unwittingly increase rather than reduce health inequalities, by not taking account of these differences.

If we take physical activity, we know from research that sporting role models appear to have little impact on participation in sport more generally. When Professor John Lyle was commissioned by SportScotland to research the question, ‘Do sporting success or sporting role models promote sports participation?’ his response to the core question was: “No impacts have been robustly demonstrated.”

We also know that having physically active parents doesn’t in itself encourage children to be physically active – but can do when children see their parents being physically active.

In practice, initiatives that encourage more physical activity tend to have an added dimension, such as:·       

  • Fun/enjoyment (of a kind play and musical accompaniment can often provide)       
  • A sense of belonging (for instance as a member of a team or community project)
  • An opportunity to enjoy nature and the outdoors (with Forest Schools a good example here)
  • Raising money for a good cause (as seen with those children who followed Captain Tom’s example during Covid).

These are all examples of ExercisePLUS, a factor we at Health Action Campaign identified, in our analysis of what approaches work best in encouraging physical activity in people more generally, including children.

Research what children think about healthy behaviours

Surprisingly, given their importance for children’s health, there seems to have been little recent research into how children themselves perceive exercise and physical activity or healthy diets. From a marketing perspective, research is an important starting point for anyone seeking to achieve behaviour change. Unfortunately, a Google search which asked, ‘Do children know that physical activity is good for health?’ produced no relevant responses, just pages of sources reporting adult perspectives.

In 2007 The National Institute for Health and Care Excellence (NICE) published, ‘The views of children on the barriers and facilitators to participation in physical activity: a review of qualitative studies.’ However, research more recently seems to have focused primarily on barriers and facilitators for children with disabilities (an important group from an inequalities perspective) rather than for children more generally.

One honourable exception was research commissioned by Sport England in 2015, exploring relevant motivations, barriers and triggers to getting more active. While the focus was primarily on women the research also included teenage girls and provided useful insights. For instance, barriers included sport and exercise rarely appealing to women’s core values or reflecting what is important for them; fear of being judged; and worries about appearance, ranging from general unhappiness about having to reveal their body to being put off by what you look like once you’ve done exercise (no make-up, hot, sweaty etc.) We know from research into social media that appearance (and the importance of maintaining often heavily curated online personas) are important for many teenage girls, so the concerns about appearance identified by the Sport England research are likely to apply to teenage girls as well as women, and this is supported by findings from the Mental Health Foundation .

The Sport England commissioned research did help inform the relatively successful This Girl Can campaign, which in just one year encouraged 2.8 million more women to do more exercise. This Girl Can, for instance, helped women and girls deal with their fear of judgement in a number of ways, from positive role models to providing a strategy for dealing with the judgement they feared.

If we are serious about encouraging children to do more physical activity, then as well as structural changes to build more enjoyable physical activity into the school day and out of school activities we need research into how children themselves perceive physical activity, exercise and sport – and how these perceptions potentially vary by age, gender, ethnic origin and social class. The same applies to diet. The more we understand what motivates and demotivates different types of children the better placed we will be to protect and develop their physical health.

Healthy Diets – beyond childhood obesity

A further point is that there has been a natural and justified focus on reducing childhood obesity in recent years, recognising both the longer-term health risks and the higher incidence of childhood obesity in deprived areas, increasing existing health inequalities. This focus has included several Childhood Obesity Plans from the government. However, a more holistic perspective would be useful here. In practice, what is good for children’s weight tends to be good for their long-term health as well. A healthy diet in particular doesn’t just help children feel fuller longer (and so less inclined to snack and gain weight). It usually provides more fibre, more nutrients and is more likely to have a beneficial impact on their gut microbiota (which is now being increasingly recognised as importantfor both physical and mental health). Physical activity too, doesn’t just help manage weight. Its range of proven health benefits led the Academy of Royal Medical Colleges to publish their Exercise – The Miracle Cure report in 2015. 

However, one major challenge is how to make healthy diets affordable, accessible and desirable for children in deprived areas and importantly for the parents who buy the household’s food - in a world where highly processed food high in sugar, salt, fat and refined carbohydrates typically seems to be cheaper, more readily available, more convenient and more extensively and persuasively advertised, as well as being bolstered by societal norms that see sweets and sweet foods as staples at children’s parties and being used to both treat and placate young children, ‘hooking’ children from an early age.

Expecting millions of people to change the habits of a lifetime is clearly unrealistic, in particular where the removal of the £20 per week uplift in Universal Credit is being followed by significant rises in both energy costs and rising food prices, and with increases in National Insurance due soon. Together these mean that cheap, highly processed food is likely to be seen as even more attractive for families and their children in deprived areas. It is unrealistic to expect such families to ‘level up’ their diets in this situation. What is needed is action from the government and the food industry.

What the food industry can do

The food industry has the expertise, the resources, and the understanding of marketing and consumer behaviour to make a positive contribution - if it wishes to. What has been missing, until very recently, as McKinsey identified some years ago, and as the British Retail Consortium has also been calling for, is the recognition by government that it needs to move beyond voluntary approaches and introduce mandatory measures, requiring companies to make healthier products.

This may be an opportune time for such measures. In practice, behind the scenes, the food industry has been looking at ways to reduce sugar, salt and fat in its products – whether to respond to potential government intervention or to take advantage of growing consumer interest in healthier products. The speed with which companies responded to the Soft Drinks Industry Levy in the UK is a good example. There have also been developments in food technology which mean it is now possible to produce foods with a lower sugar and salt content without affecting taste and without relying on artificial alternatives. A good example here was Tate & Lyle working with Nottingham University to develop SODA-LO Salt Microspheres.

This suggests the food industry may face fewer problems and enjoy greater opportunities than its lobbyists sometimes suggest, in the event of further government regulation. Indeed, food companies are already seeing the market potential of healthier food, with the soft drinks manufacturer PepsiCo, for instance, now owning both Quaker Oats and Scott’s Porridge Oats.

Meanwhile the potential to add healthy ingredients to mass produced food is also growing. For example, M&S has been fortifying its bread with Vitamin D for a number of years now and, as the Food and Drink Federation Scotland identified in its October 2020 guidance to members, adding fibre, protein, fruit and vegetables or fortifying with vitamins and minerals is one example of an approach to make a new or existing recipe healthier.

The potential to add fibre, protein, fruit and vegetables to mass produced food should therefore be encouraged, as a complementary approach potentially feasible for food companies and beneficial to children’s health.

The independent National Food Strategy

In an ideal world, all families, whatever their circumstances, would have the budgets, skills and kitchen facilities to prepare naturally healthy food, with minimal reliance on processed food and Government action would have ensured healthier food is more available and affordable and limited the promotion of unhealthy food (not just to children but to the parents who may determine their children’s food choices). However, as we don’t currently live in such an ideal world, in the short term, a useful first step would be to implement the independent National Food Strategy, including:

- A sugar and salt reformulation tax, with a £3/kg tax on sugar and a £6/kg tax on salt where these are sold for use in processed foods or in restaurants and catering businesses – and the proceeds used to support lower income families through increasing access to healthier food.

- Extending free school meals to all children in households currently earning less than £20,000; funding the Holiday Activities and Food Programme for the next three years; Expanding the Healthy Start Scheme; and trialling a “Community Eatwell” Programme for GPs to prescribe fruit and vegetables to people facing food insecurity or diet-related ill health. https://www.nationalfoodstrategy.org/

 

Michael Baber

February 2022