Evaluation of the Child Health Check Initiative and the Expanding Health Service Delivery Initiative - Final Report

4.5 Impact of the CHCI on health status

Evaluation of the Child Health Check Initiative and the Expanding Health Service Delivery Initiative - Final Report

Page last updated: 17 April 2012

4.5.1 Treatment provided
4.5.2 Change in health status
4.5.3 Social determinants
4.5.4 Conclusions

This section assesses whether the health of Aboriginal children has changed as a result of the CHCI. It addresses three main questions:

  • What specific treatment was provided as part of the child health check and follow-up services?
  • Has health status changed?
  • Have social determinants of health changed?

4.5.1 Treatment provided

Data on treatment provided as part of the child health check and follow-up services has been sourced from child health check datasets, monitoring reports and from the AIHW.

The number of children treated during their child health check is shown in Table 28. Just over half (53.2 per cent) of all children who received child health checks were treated with at least one medication, while 626 children (6.7 per cent) were given a vaccination.


Table 28: Medications and vaccinations provided to children who had a child health check (July 2007–30 June 2009)
Type of medicationNumber of children treatedPer cent of children who were treated
Medication for de-worm treatment2,93831.4
Medication for skin disease1,83819.6
Antibiotic1,34614.4
Medication for blood, blood-forming organs and immune mechanism6707.1
Medication for ear disease4574.9
Medication for endocrine/metabolic and nutritional disease3714.0
Medication for neurological disease1321.4
Medication for other diseases1551.7
Children who were treated with at least one medication4,98953.2
Provision of vaccination during health check6266.7
Total children who received child health checks9,373100.0

(a) - One child can have more than one type of medication.
Source: AIHW and DoHA (2009).

Top of pageThe number of children who had a medical procedure during their child health check is shown in Table 29. A total of 328 children (3.5 per cent) had at least one medical procedure during their check.


Table 29: Medical procedures performed during child health checks (July 2007–30 June 2009)
Type of procedure
Number
Per cent(a)
Cleaning ear
175
47.4
Skin dressing
155
42.0
Other procedures
39
10.6
Total procedures performed in child health check
369
100.0
Children who were treated with at least one medical procedure
328
3.5
Total children who received child health checks
9,373

(a) - Represents either the percentage a procedure represents out of total procedures, or the percentage of children treated out of total children. One child can have more than one type of medical procedure.
Source: AIHW and DoHA (2009).

We have not been able to access data on treatment provided to children as a result of audiology followup services. For the 3,165 children who had an audiology check on or before 30 June 2009, 75.6 per cent required further action. The most common types of further action required were: case management by PHC (50.1 per cent), ongoing monitoring by NT hearing services (46.4 per cent) and case management by ENT specialists (43.9 per cent) (AIHW and DOHA 2009).

Table 30 shows the types of services provided to the 4,346 children who received a dental check as part of the CHCI on or before 9 July 2010. Almost all (95.7 per cent) children received a diagnostic service, while over two thirds (69.7 per cent) received preventative services and almost half (47.8 per cent) restorative services. Almost one in six children (15.9 per cent) required a surgical service.


Table 30: Dental services provided to children who received a dental check as part of the CHCI (9 July 2010)
Dental service provided
Number
Per cent
Diagnostic
4,160
95.7
Preventative
3,031
69.7
Restorative
2,081
47.8
Surgery
692
15.9
Endodontic
94
2.1
Periodontic
51
1.1
Crown or bridge
23
0.5
Orthodontic
6
0.1
Prosthetics
1
0.0
Other
289
6.6
Total number of children
4,346
100.0

Source: Data supplied by AIHW (August 2010).

The dental problems treated through the CHCI dental checks on or before 9 July 2010 are shown in Table 31. Over half of children who received a dental check were provided with oral health education (59.6 per cent) or treated for previously untreated caries (52.2 per cent). Around one quarter (25.5 per cent) were treated for inadequate dental hygiene (including plaque and calcification).


Table 31: Dental problems treated during dental checks as part of the CHCI (9 July 2010)
Problems treated
Number
Per cent
Oral health education
2,594
59.6
Untreated caries
2,271
52.2
Dental hygiene
1,111
25.5
Mouth infection or mouth sores
327
7.5
Gum disease
126
2.8
Abnormal teeth growth
53
1.2
Broken or chipped teeth due to trauma
59
1.3
Missing teeth
15
0.3
Other
865
19.9
Total number of children
4,346
100.0

Source: Data supplied by AIHW (August 2010).

Data on the hospital services received by children who had a referral from a child health check provides another indication of the type of treatment provided as a result of the CHCI. Up to 30 June 2009, 1,526 (24.0 per cent) of children who had a referral from their child health check received 3,485 hospital services. Of these children 326 were hospitalised at least once and the most common causes of hospitalisation were ear disease and diseases of the oral cavity, salivary glands and jaws. In addition, 1,433 children received hospital outpatient services, which mainly consisted of visits to paediatricians, physicians and ENT specialists (AIHW and DoHA 2009).Top of page


4.5.2 Change in health status

This section primarily draws on three sources of information—existing data from NT collections on health status, analyses of the child health check dataset on change in health status over time and qualitative information collected through the evaluation case studies.

Trends in Aboriginal health status

In this section we show change in the health status for a selection of headline indicators relevant to Aboriginal health. The purpose is to situate the CHCI on the trajectory of Aboriginal health status to see if the program may have had an impact on that trajectory. We expected that it would be too early to measure whether the health status of Aboriginal children who received a child health check or follow-up service had changed, and whether any change is significant. At the very least, however, the analysis will show what was going on in the background for the CHCI target population and provide a baseline and trend data for the period leading up to the CHCI. This is important contextual information that we felt has been missing from existing program progress reporting and important as a baseline for measuring future change.

The specific indicators were selected on the basis of the ready availability of existing data for the period of interest (the years leading up to and immediately following the CHCI), and indicators that would provide a reasonable measure of the overall health status of the population of Aboriginal children living in remote areas of the NT. We also included one or two health conditions which we might reasonably expect the CHCI to influence over the shorter-term.

Trend information for hospitalisation in the NT from 1992–93 to 2007–08 (Li et al 2010) generally shows increased hospitalisations for Indigenous people. Underlying this is a dramatic increase in non-communicable diseases (NCDs). For several NCD conditions—diabetes, asthma and intentional self-harm—the separation rate more than doubled over this period. For diabetes the increase was over 600 per cent. The separation rate also decreased by a considerable extent for a number of communicable diseases—tuberculosis for Aboriginal males by 43 per cent and females by 50 per cent and acute respiratory disease by 53 per cent for males and 28 per cent for females.

Progress is being made in maternal health (Zhang et al 2010). The total fertility rate for Indigenous women declined from 1986–2005, especially for teenage Indigenous women. The proportion of Indigenous mothers attending their first antenatal visit during the first trimester more than doubled, from 16 per cent in 1986 to 38 per cent by 2005. This improvement was particularly evident among Indigenous mothers living in the remote health districts of East Arnhem and Alice Springs Rural. The proportion of Indigenous mothers birthing outside a hospital decreased markedly from 1986–2005. Top of page

A steep decline has occurred in the Indigenous fetal death rate (Figure 7). This rate more than halved, falling from 24 to 12 fetal deaths per 1,000 total births from 1986 to 2005. The Indigenous neonatal death rate also fell, but to a lesser extent.


Figure 7: Fetal, neonatal and perinatal average annual death rates, NT Indigenous residents, by five-year periods (1986–2005)

Figure 7: Fetal, neonatal and perinatal average annual death rates, NT Indigenous residents, by five-year periods (1986–2005)

Source: Zhang et al (2010)


[D]

Child health check datasets—changes over time

A small number of children received more than one child health check or audiology check under the CHCI. The AIHW looked to see if there had been any change in their conditions between each check (AIHW and DoHA 2009). It is not known how the group of children that received more than one check differs from the group who received just one.

There were 159 children who had more than one valid child health check (AIHW and DoHA 2009). This cohort is too small to assess the change in health status at a population level with any confidence. The key purpose in reporting it here is to show the potential impact on the point prevalence of common conditions or the appearance of new cases within the population.

As shown in Table 32 all children who were diagnosed with trachoma (five children) and ringworm (12 children) at their first check no longer had these conditions at their latest check. There were also high levels of recovery for scabies—only 1 of the 14 children (7.1 per cent) diagnosed at their first check still had the condition at their latest check. For skin sores, 2 of the 23 children (8.7 per cent) diagnosed at their first check still had the condition at their latest check.


Table 32: Changes in health conditions between first and latest child health check(a) for Aboriginal children who had at least two child health checks (July 2007–30 June 2009)
Children with the condition at first check
Children still with the condition at latest check
Children with a new condition at latest check
Total children with condition at latest check
Number
Number
Per cent
Number
Number
Ears and eyes
Ear disease
45
15
33.3
34
49
Trachoma
5
0
0.0
1
1
Oral health
Untreated caries
72
47
65.3
16
63
Any oral health issue
76
50
65.8
14
64
Skin
Skin sore (4 or more)
23
2
8.7
9
11
Scabies
14
1
7.1
3
4
Ringworm
12
0
0.0
7
7
Any skin problem
49
10
20.4
16
26
Anaemia
Anaemia
31
8
25.8
28
36
Physical growth
Growth problem
32
14
43.8
15
29
Other
Immunisation due
24
1
4.2
9
10
Total children
159
0.0
159

(a) - The minimum time between receiving two child health checks was nine months.
Source: AIHW and DoHA (2009).

The appearance of new cases within the population of children who had more than one child health check meant the prevalence rate of these conditions remained at similar levels between first and latest health checks. So the number of children with ear disease, oral health problems, anaemia and growth problems are similar at both checks (first and last data columns in Table 32).

There were 1,091 children who had two or more audiology checks as at 19 July 2010 as part of the CHCI. The average period of time between the first and last check was 164 days (around five and a half months). The proportion of children who had no hearing loss increased from 24.3 per cent at the first check to 35.7 per cent at the latest check, while the proportion of children with unilateral and bilateral hearing loss decreased between the first check and the latest check (Table 33).Top of page


Table 33: Hearing loss at first and last check, for Aboriginal children who had at least two audiology checks (19 July 2010)
Hearing loss
First check
Latest check
Number
Per cent
Number
Per cent
None26524.338935.7
Unilateral27625.323721.7
Bilateral52247.945041.3
Missing282.6151.4
Total1,091100.01,091100.0

(a) - Missing includes unsure, invalid, not stated and not tested responses.
Source: Data supplied by AIHW (August 2010).

The AIHW also examined the change in the degree of hearing impairment for the 1,091 children who had two or more audiology checks. The results show that the proportion of children with no hearing impairment increased between first check and latest check (from 52.4 per cent to 60.0 per cent), while the proportion of children with a mild or moderate degree of hearing impairment decreased between the first check and the latest check (from 28.6 per cent to 27.1 per cent for mild, and 16.1 per cent to 11.1 per cent for moderate) (AIHW and DoHA 2009).23

At the time of their first audiology check 514 children had at least some hearing impairment. Table 34 shows the proportion of children whose level of hearing impairment had improved, deteriorated, or stayed the same from their first to latest check (for checks completed on or before 19 July 2010).

The trend for this cohort with two or more audiology checks, albeit a small sample, is towards improvement in hearing. This is encouraging; however, the table also shows deterioration in hearing for over one third of children found to have hearing impairment at the first check (almost half of the cohort of 1,091). Any changes in the degree of hearing impairment may be attributed to the treatment provided through the CHCI, factors that affected diagnosis (such as doctors’ knowledge of diseases and the equipment used for testing), or changes associated with social determinants. It is important to note that the biggest variable is the natural history of audiology conditions. These tend to be chronic and recurrent rather than deteriorating, so some fluctuation in the degree of hearing impairment between checks is to be expected.Top of page


Table 34: Changes in degree of hearing impairment between first and latest check for Aboriginal children who had at least two audiology checks (19 July 2010)
Degree of hearing impairmentNumberPer cent
Improved28054.5
Deteriorated17534.1
No change367.0
Missing234.5
Total514100.0

Source: Data supplied by AIHW (August 2010).

Case studies

Participants in case study interviews were asked if they felt that there had been any change in the health status of Aboriginal children since the NTER and whether they thought any changes were attributable to the CHCI. The case study fieldwork was conducted from February–April 2010—a maximum of 33 months since the child health checks.

The general view was that children’s health had not changed since the NTER. In the words of one staff member at a health centre, ‘we see the same old problems month in and month out’ (interview, health centre staff member). There was a feeling that oral health had improved due to the services provided, given that the baseline in access to dental services was so low before the CHCI. There was also a feeling that the dental services were focusing on treating symptoms rather than causes and that improvements may not be sustainable. There was a view that the large number of audiology checks and improved access to specialist care may have temporarily reduced the prevalence of ear disease, but that the small amount of surgery done was ‘nothing that would change the long-term health of the population’ (interview, health professional).

The following points summarise many of the responses from interview participants:
  • Because child health checks were happening before the child health check program, it would be difficult to attribute any changes to the CHCI.
  • In communities where the majority of follow-up has not been completed, it is very difficult to say the CHCI has had any impact.
  • It is difficult to isolate any impact of the CHCI from the impact of other NTER measures. In its health impact assessment in 2010, the AIDA concluded that there had been no improvement in child health and safety as a result of the CHCI. The AIDA also noted the lack of focus on protective factors, quoting an Aboriginal corporation:
I still question the fact that you know we’ve got these health checks happening, children are being seen maybe once, maybe twice and then they’ve been sent straight back into the environments that gave rise to their illnesses and conditions in the first place.


4.5.3 Social determinants

Access to healthcare is only one of the many factors influencing health outcomes. As Ostlin et al (2009) point out, both health systems and the people who use them exist within a social context that affects the health of individuals through access to a range of resources and opportunities—the social determinants of health.

‘Social determinants of health’ are the conditions into which people are born, where they grow up, live, their work and age and the systems put in place to deal with illness (WHO 2008a). Specifically, this includes the economic, social and physical conditions that influence the health of individuals and communities. Population health is malleable and sensitive to the social environment. Poverty, social exclusion, low quality housing and limited access to health systems are the main social causes of poor health (WHO 2003).
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Social determinants of health are largely responsible for the avoidable differences in health status within and between countries. Health and illness follow a common social gradient—the lower the socioeconomic position, the poorer the health outcomes of a population (WHO 2008b). Inequalities in health status are apparent between privileged and less privileged groups within Australia. There is a significant gap in life expectancy between Indigenous and non-Indigenous Australians. From 2005–2007 the life expectancy at birth for Indigenous people was estimated at 67 years for males and 73 years for females, compared with 79 years and 82 years respectively for the total Australian population (AIHW 2008a).

The Cooperative Research Centre for Aboriginal Health (2004) identifies the following as key determinants of Aboriginal health and wellbeing:
  • housing
  • education
  • social networks and connections
  • physical infrastructure
  • connection with land
  • racism and discrimination
  • employment
  • law enforcement and the legal and custodial system.
The inter-dependence of these factors makes it difficult to assess the relative importance of each determinant (Bailie et al 2009). Within the evaluation case studies, the issue most often identified as critical, particularly by the parents and guardians we interviewed, was the housing situation in remote Aboriginal communities. As one staff member put it, ‘Health is “just” the outcome, [they] need to consider other factors that contribute to this outcome, not least housing and education’.

This concern is echoed by several commentators. Poor quality housing is identified by Bailie et al (2009) as a major underlying factor in poor child health in remote Indigenous communities in Australia. Housing affects health in several ways—whether there is enough space for all residents to live comfortably, whether there is adequate water supply and hygiene and whether the house has the necessary physical attributes, such as ventilation, to ensure a healthy environment (Maier 2006; Bailie et al 2009). Housing was recognised by the WHO Commission of Social Determinants of Health as a key factor in poor health outcomes, noting that those living in poor quality housing that is overcrowded are more likely to suffer from physical and mental health problems (WHO 2008b). One study found that 30 per cent of Indigenous family and group households in rural areas were overcrowded (Neutze et al 2000, cited in Long, Memmott and Seelig 2007).

As part of the evaluation we used a social determinants health assessment tool (see Appendix G), developed by the Menzies School of Health Research (MSHR 2006), to get a baseline measure of where each case study community sat on a range of indicators. We did this to provide a context for our analysis of the impact of the CHCI, and also to establish a community baseline that could be used in future monitoring and evaluation studies. We also considered social determinants within the formative evaluation of the EHSDI and, in particular, explored the role the NT PHC system might play in social determinants in the future. This discussion is included in Section 5.4.2.

The assessment tool involved rating the various indicators on a scale of 0–11 (0–1 being ‘very poor’, 2–4 being ‘poor’, 5–7 being ‘satisfactory’, 8–10 being ‘good’ and 11 being ‘excellent’). The chosen indicators were selected because they relate specifically to living conditions, which were identified by evaluation participants as a critical issue in the case study communities.24 Staff of the shire or community council in the five case study communities undertook the assessment.

The results, shown in Table 35, match the stories we heard about the poor condition of housing, with the ‘healthy housing’ indicators scoring, on average, as ‘poor’ and significantly lower than the other factors.


Table 35: Results of social determinants health assessment (February–March 2010)
CommunityABCDEAverage score
Water supply
Delivery system7710626.4
Drinking water31011667.2
Rate of supply447986.4
Sewerage system
Sewerage system(a)210676.25
Final effluent disposal8510677.2
Solid waste disposal
Delivery system757375.8
Household level10487107.8
Community level937696.8
Electricity supply
Access to electricity10511647.2
Safety7711647.0
Healthy housing
Personal hygiene337534.2
Laundry437233.8
The ability to safely store and prepare healthy food525253.8

(a) - Community had septic tanks so no effluent stabilisation ponds.

Education, particularly school attendance, was often mentioned as a major problem in many communities. It is commonly accepted that higher education levels leads to improved population health status (Bell et al 2007). School attendance is important for developing literacy and also for its influence on socialisation and developmental processes. These are recognised as important determinants of health both during school years and later in life (Maier 2007). For this reason we have sourced some data on school attendance in the five case study communities that may again provide a benchmark for future monitoring and evaluation activities (Table 36).
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Table 36: School attendance rates (2008–10)
Community
Attendance rate (%)
2008
2009
2010
A
66
71
66
B
46
56
53
C
38
60
47
D
60
63
64
E
59
68
64
Average
64
64
59

Source: Australian Curriculum, Assessment and Reporting Authority (http://www.myschool.edu.au/).

Future policy considerations

As outlined above, low living standards in remote Aboriginal communities are a potent factor in determining health outcomes. Housing, education and other social determinants influence lifelong trajectories. The WHO Commission on Social Determinants (WHO 2008b) recognises child poverty and the intergenerational continuation of low social and economic circumstances as major obstacles to improving population health and improving health equity.

There is growing acknowledgment that the factors that make up social determinants of health are malleable and can be influenced by changes in public policy (Anderson et al 2007). Interventions to treat existing disease, when planned and executed well, are essential and should continue to be given a high priority, but should not preclude policy action on the underlying social determinants of health (Marmot 2005). While disease control and providing access to medical care may produce some health gains, long-term success in improving population health can only be achieved by wider social development.

When considering any potential future intervention, coherent policy action is required (WHO 2008). Future policy needs to focus on the broader aim of relieving poverty and improving the economic and social conditions in remote Aboriginal communities. Provision of access to quality medical care, linked with better housing, education and employment opportunities are critical to improving Aboriginal health (Anderson et al 2007).


4.5.4 Conclusions

A significant amount of treatment was provided as part of the child health checks (4,989 children were treated with at least one medication) and the follow-up services, particularly dental services (4,346 children had dental treatments).

Many of the diseases found during the child health checks and follow-up services are acute infectious conditions or chronic episodic conditions that could potentially change within the time frames of this evaluation. The limited trend data that we have is contradictory. On the one hand it suggests improvement in hearing with a decrease in the number with any hearing loss between their first and last audiology check. On the other hand, the deterioration in hearing impairment for over a third of children who had some impairment at the time of their first check, suggests follow-up services have not been effective on their own. The reoccurring nature of ear disease in Aboriginal children is likely to be a significant factor in explaining the differences.

We have previously commented on the inefficiencies in the way the follow-up services were initially planned and delivered and it is likely that this had an impact on the effectiveness of follow-up services. The positive impact of the CHCI on health service delivery models for dental and hearing services is leading to more efficient ways of providing these services and is likely to contribute to their effectiveness in the future, providing these services continue to be funded and are developed within the context of a comprehensive PHC approach. However, even with adequate follow-up, medical intervention in the context of ongoing poor social determinants, particularly in the area of healthy housing, may impact on the health of individual children in the short term, but will have little or no impact at a population level as children simply get re-infected or continue to live in conditions that promote or exacerbate chronic illness.

23 - The audiology check is not in itself a treatment and therefore any change in hearing impairment cannot be attributed to having a check.
24 -Other indicators which were not included in this evaluation, but are particularly relevant to people living in remote Aboriginal communities, include access to food, over-crowding and transport.

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