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Learning objectives
After studying this chapter, you should be able to:
recognise how changes in family lifestyles have led to increased child overweight and obesity
understand the impact of poor child oral health on child health and wellbeing, and opportunities for intervention
have knowledge of the ways in which same-sex parent families are formed and how resilience building can be used to improve the health of children affected by stigma
have knowledge of the risk and protective factors for child mental health.
Schools and other childhood settings provide an ideal context for the multi-level interventions necessary for obesity prevention. The fun ‘n healthy in Moreland! trial was a five-year primary school-based health promotion and obesity prevention program led by the University of Melbourne in partnership with Merri Community Health Services, Moreland City Council and 23 primary schools in a culturally diverse, urban area of Melbourne from 2004 to 2009 (Waters et al., 2008). The fun ‘n healthy in Moreland! program demonstrated success in working with schools to change school policies, programs and environments to promote healthy eating, physical activity and wellbeing. The Health Promoting Schools Framework was a helpful socio-ecological model that guided school strategies, allowing them to customise their efforts to their school community. Successful approaches were characterised by strong leadership announcing decisive change from the beginning of the next school year (such as changing a canteen menu from a diverse range of mostly unhealthy choices to three healthy items – soup, rolls, smoothies), involvement of children in decision making (for example, taste testing for canteen menus), change in school policies (such as drinking water policies so that children could bring only water to school as a drink), playground equipment (for example, loose equipment such as balls and other sport equipment regularly replaced), and innovative programs that engaged the school community (for example, ‘nude food’ days that aligned with the environmental program where children were asked to bring only unpackaged food for school lunches). A gradual generational shift was evident in the schools in response to the strategies. The fun ‘n healthy in Moreland! program also developed a careful body image sensitivity protocol to ensure that, by addressing overweight and obesity, it did not inadvertently contribute to body image concerns among the children (Gibbs et al., 2008). In doing so, it became apparent that the main message of any health promotion and obesity prevention initiative needs to be clearly on valuing and taking care of your body, and not creating the impression that the intent is on fixing body ‘faults’ or making you look ‘better’.
- Health promotion
initiatives that aim to enable healthy lifestyles and behaviours based on Ottawa Charter principles.
- Socio-ecological model
a model taking into account the range of influences on individuals arising from interacting genetic and biological factors and social, cultural, physical, political and economic environments.
Introduction
Children and young people have the right to be healthy and to maximise their opportunities for a fulfilling life. This is enshrined in the 1989 United Nations (UN) Convention on the Rights of the Child which outlines children’s rights to health, safety, wellbeing and citizenship (UN, 1989). This UN convention defines childhood as below the age of 18 years but acknowledges that in some countries the age of adulthood is considered to begin at below 18 years. Age ranges for youth services may also extend up to 25 years in other countries. This highlights the fact that childhood is a social construction that has shifted through history and across nations and cultures, influencing theoretical frameworks for childhood and hence opportunities for children. For example, the notion of the ‘child at risk’ represents children as vulnerable and in need of protection; the ‘developing child’ represents children as in the process of becoming an adult and therefore in need of support and representation until their maturity and competencies have fully developed; and the ‘citizen child’ conceptualises children as capable of contributing to decisions affecting their lives (Gill, 2007; Leonard, 2007; MacDougall, 2009; Morrow, 2003). These theoretical frameworks are not necessarily mutually exclusive and can have joint influence. For example, in a post-disaster setting, children can be provided opportunities to participate in post-disaster research (citizen child), using child-friendly methods that are positive and relevant to the age and stage of the child (developing child), and ensuring a sensitive and ethical approach is employed so as not to increase the trauma experience (child at risk) (Gibbs, Mutch, O’Connor & MacDougall, 2013).
Children’s smaller size and developing but not fully matured physical, intellectual and social competencies mean they are often more vulnerable than adults to threats to physical and mental health and wellbeing. Children’s life circumstances and the health behaviours they develop will also influence their health over their life course (Halfon & Hochstein, 2002). The various elements of their life circumstances are known as the social determinants of health and they are reliable indicators of inequalities in health and social outcomes (Marmot & Wilkinson, 2005). Therefore, child public health considerations do not just need to address the current health status of the child; they also need to address the health issues that may emerge from children’s current circumstances and lifestyle.
A socio-ecological framework is helpful in recognising these multi-level influences on health and wellbeing. Socio-ecological frameworks acknowledge the biological elements of health and the importance of individual behaviours (Bronfenbrenner, 1979; Dahlgren, 1991; Lynch, 2000). At the same time, they recognise a number of other influences, including the family and socio-cultural context; school and community settings; and the macrophysical, political and economic environment that alters living conditions and opportunities for health-promoting behaviours. Children’s direct interaction with these different levels of influence increases progressively over time as they mature, but is mediated throughout by adult guardians, including parents and teachers. The role of these mediators needs to be included in any efforts to implement change in the spheres of influence on child health and wellbeing, such as in the home, school and community settings.
This chapter explores socio-ecological influences on child health and wellbeing by examining obesity prevention, oral health, the experiences of children in same-sex parent families and mental health. In doing so, opportunities to reduce child health inequalities and to increase resilience and quality of life are discussed.
Child obesity prevention
Overweight and obesity have emerged in recent decades as international public health issues affecting children at unprecedented levels (World Health Organization, 2012). It is estimated that 42 million children worldwide under the age of five years were overweight or obese in 2013, with rates having trebled in some countries since 1980 (World Health Organisation, 2015). The health implications of overweight and obesity in childhood and adolescence are severe and include increased risk of cardiovascular conditions, diabetes, joint problems, sleep apnoea and poor self-esteem. They are also associated with increased risk of adult obesity and higher adult morbidity and mortality. The establishment of healthy dietary and physical activity behaviours for young children may help prevent the onset of overweight or obesity in adolescence and adulthood. However, the population-level epidemic reflects the fact that the individual behaviours are being driven by broader social and environmental changes.
Obesogenic environments
The term ‘obesogenic environments’ describes conditions that make it harder to be healthy by reducing opportunities for physical activity and healthy eating in everyday life (Swinburn, Egger & Raza, 1999). For example, neighbourhoods with limited public transport, unsafe cycling conditions and lack of direct walking routes, force a reliance on car transport rather than active transport. Similarly, public spaces such as sporting facilities which offer only high sugar and high fat food and drinks for purchase, and sporting clubs that hand out fast food vouchers to children as rewards, make it difficult for healthy eating choices to be made.
Obesity prevention initiatives
Child obesity prevention initiatives ideally involve a multi-level approach to effect sustainable change in target communities (Waters et al., 2011). This includes a combination of policy, program and environmental strategies in recognition of the different levels of influence on child health and behaviours. Settings-based approaches allow for multi-level strategies and, as such, interventions are commonly situated in communities, schools, and early childcare settings. It is important in these settings to account for the local social, cultural and historical context. For example, the fun ’n healthy in Moreland! study, conducted in culturally diverse communities, included guidelines for Muslim parents and schools to support children’s healthy eating and physical activity during the fasting period of Ramadan.
Traditional and social media can also be used by governments and interest groups to promote healthy eating and physical activity and to reduce the development of obesogenic environments.
School-based obesity prevention interventions
There is a developing international evidence base that indicates that school-based obesity prevention interventions can increase healthy behaviours and improve children’s weight status (Waters et al., 2011). School-based obesity prevention interventions can be implemented through government, academic, service provider, school and community initiatives. For example, federal and state governments in Australia have school canteen guidelines to promote healthy canteen menus, and physical activity guidelines to set minimum levels of weekly physical activity sessions for children in school curriculums. However, without monitoring there are often low levels of compliance (de Silva-Sanigorski, 2011).
Community-led initiatives
Community driven initiatives can help to maintain the momentum for change when funding shortages, staff turn-over and political changes undermine continuity of efforts. The Parents’ Jury is an online forum established by parents to provide a means for parents, grandparents and carers to advocate improved food and physical activity environments for children, including ‘Fame and Shame’ awards for industry marketing techniques and government policies (http://www.parentsjury.org.au).
Impact of public health campaigns
There is some evidence to suggest that increased awareness and changing environments arising from multi-level public health campaigns are starting to make a difference at a population level with recent measures of child overweight and obesity in Australia indicating that prevalence rates are declining (Olds, Tomkinson, Ferrar & Maher, 2010). Prevalence rates appear to have settled to 21–25% for overweight and obesity. However, persistent prevalence of one in four children overweight or obese is still not acceptable for promoting long-term population health. Rates may still be increasing for disadvantaged population groups.
Generational changes in lifestyles contributed to the escalating rates of child overweight and obesity internationally. The car is now the primary form of transport, reflecting a significant shift away from children walking or riding to school. This is partly due to parents’ concerns about children’s safety as pedestrians and cyclists. It has also shifted because of the increasing trend of both parents working and an increase in single-parent households, and so many children are now being dropped at school as parents drive to work. Families tend to be smaller so children have fewer siblings to play with outside after school. Parents are less likely to allow their children to go to a park by themselves because of concerns about ‘stranger danger’. Busy parents are relying on the increased availability of high-density packaged foods for their children’s lunchboxes. Families are regularly eating unhealthy foods that used to be occasional parts of the family diet. The increased popularity of screen activities means that children are also less engaged in active play after school and on weekends. Children are being given mobile phones at younger ages as a means of communication with parents. Computers and tablet devices are also being used by schools as part of children’s education. This means that the traditional ‘play time’ during breaks at school is increasingly shifting away from active play in school grounds to sedentary screen-based entertainment.
Child oral health
Oral health includes the health of teeth, gums and other tissues of the mouth. Pain, disease or disorders affecting oral health can affect many aspects of people’s lives including speaking, eating, smiling and wellbeing. The importance of oral health as a major public health concern internationally was demonstrated by its inclusion in Article 19 of the United Nations’ 2011 Political Declaration on Prevention and Control of Non-Communicable Diseases (NCDs) (United Nations General Assembly, 2011). It was noted that oral diseases share many of the risk factors of other NCDs, such as healthy diets, and so will benefit from shared efforts to promote health.
Conditions affecting child oral health include gingivitis, which is characterised by swelling, redness and bleeding of the gums. If left untreated, gingivitis can progress to periodontitis, an advanced inflammatory form of gum disease affecting the structures that surround and support the teeth. However, this can be prevented and treated through regular tooth brushing, flossing and professional dental care. Another condition affecting children’s oral health is early childhood caries (ECC). This is the focus of this section because it is the main oral health issue affecting the health and wellbeing of children. It is a particularly severe form of dental caries and is the most common and preventable disease of early childhood (Gussy, Waters, Walsh & Kilpatrick, 2006). ECC is defined as the presence of any decayed, missing or filled tooth surfaces in the primary teeth of children under the age of six years. It is an international public health problem but rates of prevalence vary considerably from 2.8 to 85%, with higher rates more evident in developing countries (Kawashita, Kitamura & Saito, 2011).
Inequalities in child oral health appear as early as two years of age, with those from socially disadvantaged circumstances, particular geographic locations, indigenous families, and migrant and refugee families showing poorer oral health than the wider population (Kilpatrick et al., 2012; Lucas, Neumann, Kilpatrick & Nicholson, 2011; Riggs et al., 2013). ECC is often dismissed as unimportant because children’s first teeth (primary dentition) are eventually replaced by their adult teeth (permanent dentition). However, it can cause illness, pain, abscesses, disturbed sleep, difficulty eating and speaking, and can lead to poor oral health in adolescence and adulthood (Cunnion et al., 2010; US Department of Health and Human Services, 2000). It can also affect self-esteem and social interactions, as well as school attendance and academic outcomes (Jackson, Vann Jr, Kotch, Pahel & Lee, 2011; Sheiham, 2006). Severe cases can result in hospitalisation and the need for surgery and anaesthetic, with associated health risks (Nalliah, Allareddy, Elangovan, Karimbux & Allareddy, 2010; Tennant, Namjoshi, Silva & Codde, 2000).
In recognition of the multidimensional impacts of oral health, theoretical models representing oral health related quality of life have been established, to reflect the biological, social, psychological, and cultural factors affecting quality of life. Associated instruments have been developed to measure the positive and negative dimensions of oral health across the life course, including measures specifically for children and youth (Sischo & Broder, 2011).
Dental service use
The key oral health messages for prevention of ECC are to eat well, drink well, clean well and stay well. ‘Eat well’ and ‘drink well’ refer to the importance of reducing the consumption of high sugar foods and sweetened drinks. ‘Clean well’ refers to the importance of brushing teeth twice daily with toothpaste (Pine et al., 2000). The message of ‘stay well’ is to visit dental health practitioners to check on children’s oral health and to receive treatment if required. The first stages of ECC are not always visible to non-professionals and research has shown that parents of children with early stage ECC have not taken their children to see a dentist because they think they do not need it and because of lack of understanding of the need to take care of the primary dentition (Christian et al., 2015). Other barriers to service use include cost, time, and cultural and language barriers (Riggs, Gibbs, van Gemert, Waters & Kilpatrick, 2014).
Water fluoridation
Oral public health efforts have been introduced in Australia to reduce rates of ECC, including the addition of fluoride to drinking water for most Australian towns and cities (http://www.ada.org.au/oralhealth/fln/flfaqs.aspx). Despite this approach to oral health promotion, there are many rural and remote areas where ‘town water’ is not used and therefore many children miss out on the benefits of fluoridation (Gussy, 2006; Lucas et al., 2011). The existing evidence relating to fluoridation strongly supports its use in reducing dental caries (Lucas et al., 2011; National Health and Medical Research Council, 2007). When intentional water fluoridation is extended to new areas it tends to generate considerable public debate over its merit because of concerns it is ‘artificial and imposed, and any risks were not personally controllable’ (Armfield & Akers, 2010). Opponents to water fluoridation cite health risks; however, there is insufficient evidence to support these concerns (National Health and Medical Research Council, 2007).
Child oral health interventions
Oral health promotion and education interventions can be targeted at the level of individual, families or communities to address disadvantage and health inequalities. They can be delivered in various ways and contexts to promote oral health behaviours and reduce dental caries. Child dental screenings conducted in community settings can contribute to parents’ understanding of their children’s oral health needs. A shared language and culture is an important inclusion when sharing oral health knowledge with families from different cultural and language backgrounds. It is also helpful to involve community-based partners such as maternal and child health nurses and/or cultural organisations to engage families and deliver the child oral health promotion intervention. The Fisher-Owens model provides a useful guide for thinking about the socio-ecological influences on child oral health, which can then be used to plan multi-level points of intervention for child oral health promotion (Fisher-Owens et al., 2007).
During the ‘Teeth Tales’ study, a range of socio-cultural risk and protective factors affecting child oral health were identified for families with a refugee and migrant background living in Melbourne, Victoria, Australia. As part of the study, migrant families from Iraq, Lebanon and Pakistan were invited to participate in a trial of a community-based program. Dental screenings were conducted for 667 children aged one to four years, and 151 families attended community oral health education sessions led by someone from their own language and cultural background. The sessions included information and discussions about the key oral health care messages with the peer educator, a visit to the local community dental service, a family oral health pack with information, toothbrushes and toothpaste, and follow-up reminder messages to eat well, drink well, clean well and stay well. At the same time the participating community health and local government organisations underwent a cultural competence review and reorientation of services to increase their accessibility.
The trial evaluation showed improved oral hygiene for children from intervention families compared to the comparison group, as well as increased parent knowledge on tooth-brushing technique and the role of fluoride in water (Gibbs et al., 2015). The participating organisations also demonstrated changed policies and programs to improve cultural competence. The study informed the refugee access policy for Dental Health Services Victoria. Ongoing ‘Teeth Tales’ outcomes include publication of the peer oral health education program for wider use in culturally diverse community settings1, and publication of the Cultural Competence Organisational Review resources2. Lead agency, Merri Community Health Services, also reoriented their dental services to include a new oral health program called ‘Little Smiles’ where dental screenings and oral health education are provided to children in preschool settings, with treatment referrals provided as required.
What strategies may be helpful to target child oral health interventions to families from different cultural and linguistic backgrounds?
Children in same-sex parent families
There are an increasing number of children in Australia growing up with at least one parent who identifies as being same-sex attracted. Commonly referred to as same-sex parent families, these families have been formed in a variety of ways with a range of intra-familial relationships. Same-sex parent families include families with gay male parents, lesbian parents, bisexual parents, single parents and transgender parents. Children can come into these families from previous heterosexual relationships, through the use of assisted reproductive technologies and surrogacy, or via fostering and adoption. However, same-sex parent families have been formed, child health and wellbeing in this context garners a lot of social and political interest and has been the subject of a growing body of research.
- Same-sex parent family
any family where at least one parent identifies as being same-sex attracted.
Biological or social parenting?
The social context of same-sex families has evolved. There has been a transition from ‘stories of impossibilities’ through ‘stories of opportunities’ to ‘stories of choice’ (Weeks, Heaphy & Donovan, 2001). Having children was once an ‘impossible’ concept for non-heterosexual people as ‘coming out’ ruled out marriage, the only realistic option to have children. Instead, families for these people were constructed in the context of their peers and friendship groups. ‘Opportunities’ to have children evolved as social and cultural shifts broadened perceptions of ‘real families’. Stacey puts this in the context of the ‘sexual revolution and feminist assertions of autonomy’ (Stacey, 1996, p. 110) that enabled lesbian women to join the growing group of women having children outside marriage. Research, media attention and the increased visibility of same-sex families allowed a growing confidence in non-heterosexual people who wanted to parent (Weeks et al., 2001). With the recent options presented by new reproductive technologies, same-sex families are finally able to make ‘choices’ about how they achieve parenthood. Where Weeks et al. talk about ‘doing parenting’ (Weeks et al., 2001), others describe ‘doing family’ – meaning family is constructed in everyday practice rather than being defined by biology alone (Oswald, Blume & Marks, 2005; Perlesz et al., 2006). In both contexts, same-sex families have gradually found a position where social parenting is given equal prominence with biological parenting. Despite a lack of community role models, negotiated social parenting plays an important role in many same-sex families.
Health and wellbeing
It is increasingly understood that, in terms of their overall health and wellbeing, children with same-sex attracted parents are developing well (Dempsey, 2013). Early research focused on psychosocial aspects of health but more recently a holistic understanding of child health in this context has been described. Evidence is starting to emerge suggesting that the health of children with same-sex attracted parents shows benefits in some areas. Recent research from Australia identified that child health related to family processes, benefits from the ways in which same-sex parent families ‘do family’, particularly in terms of shared parental responsibilities and non-gendered parenting (Crouch, Waters, McNair, Power & Davis, 2014).
Stigma
Despite these positive outcomes overall, there is clear evidence that experiences of stigma in same-sex parent families can have a negative impact on child health (Crouch et al., 2014). Stigma essentially refers to an ‘undesired differentness’ (Goffman, 1963). It is an outcome of negative social attitudes and in the 1960s, Goffman categorised homosexuality as a ‘blemish of individual character’, or unnatural passion, which is unfortunately a perspective that persists for many people today. LeBel (2008) highlights a more recent definition of stigma that brings into play the importance of social identity and notes a general understanding that members of stigmatised groups are both devalued and discriminated against thus leading to social exclusion and status loss (LeBel, 2008). Major and O’Brien build on Goffman’s categorisations, suggesting that stigmatisation can result from three key attributes – behaviour, appearance and group membership – and that members of stigmatised groups are at greater risk of mental and physical health problems (Major & O’Brien, 2005), as is the case for many same-sex attracted people and their families.
- Stigma
negative social attitudes in relation to a behaviour seen as different from the norm, leading to discrimination and social exclusion.
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