Inequalities and deprivation

Map and coins

Updated November 2013

Topic briefing

One child in five is living in poverty and two million children live in poor housing. Children from deprived families are far more likely to be killed, disabled or seriously injured in preventable accidents.

This briefing explains the key issues relating to inequalities and deprivation for senior practitioners and policymakers working in child accident prevention.

Key issues

Deprivation

One in six children in the UK - 2.6 million - is officially classified as poor. Since 2010 there has been a 15% fall in the number of children in workless households, but a big rise in the proportion of poor children who are in families where someone is in work. Two thirds of poor children are now in working households.1

The Chief Medical Officer’s report for 2012 states that 26.9% of children and young people (age 0–19) in England are in or at risk of poverty or social exclusion, compared with the overall population rate of 22.6%. It highlights that these figures compare poorly with the best performing country – the Netherlands, where 15.7% of 0-19s are in or at risk of poverty.2

In England in 2010/11, 29% of children in urban areas lived in households below the poverty threshold after housing costs. In rural areas, the proportion was slightly lower at 20%. Children are the group that are most likely to live in a household with an income below the poverty threshold after housing costs in both urban and rural areas.3

Children living in poverty are almost twice as likely to live in bad housing. This has significant effects on their physical health, mental wellbeing and educational achievement.4

Deaths

While the overall number of accidental deaths has fallen in recent years, the percentage of deaths among the poorest children has risen. There are persistent and widening inequalities between socio-economic groups for childhood deaths from accidents.5

Children from the most disadvantaged families (whose parents have never worked or are long-term unemployed) are 13 times more likely to die in accidents than children of parents in higher managerial and professional occupations. (Figure 1).6

Figure 1. Injury death rates per year per 100,000 children aged 0-15 years by National Statistics Socio-Economic Classification (eight class NS-SEC), 2001-03, England and Wales 6

Inequalities

The socio-economic gradients for deaths vary considerably by accident type:

  • for pedestrian deaths, the rate in families where parents have never worked or are long-term unemployed (NS-SEC 8) is 20 times higher than in families with parents in higher managerial/professional jobs (NS-SEC 1)
  • for cycling deaths it is 27.5 times higher
  • for fire deaths it is 37.7 times higher.6

Other research confirms these variations, showing that childhood deaths from road and fire accidents are significantly higher in poorer households. Deaths from pedestrian accidents, suffocation and drowning also have a strong connection to socio-economic circumstances.7

Hospital admissions

Children from the most disadvantaged families are also more likely to be admitted to hospital after an accident and to be admitted with more severe injuries. Research in the Trent region showed that both the total number of admissions for accidental injury and admissions for injuries of higher severity increased with socio-economic deprivation. These gradients were more marked for 0-4 year olds than 5-14 year olds.8 The steepest socio-economic gradients were for:

  • pedestrian injuries (rate ratio 3.65)
  • burns and scalds (rate ratio 3.49)
  • poisoning (rate ratio 2.98).

There is also variation in serious accidental injuries in children according to the level of deprivation in an area. Research reviewing hospital admission rates for serious injury to children aged 0-15 in lower super output areas (geographical areas designed for the collection and publication of small area statistics) in England between 1999 and 2004 6 showed:

  • for child cyclists, rates of serious injury were three times higher in the most deprived areas than in the least deprived
  • for child pedestrians, rates of serious injury were four times higher in the most deprived areas than in the least deprived.7

The research also found that rates of serious pedestrian injury varied by location, being lower in towns, suburbs and villages than in urban areas. Steeper socio-economic gradients in serious injury rates were identified in rural areas for cyclists and for children suffering falls.The research concluded that overall socio-economic inequalities in serious injury were particularly strong for child pedestrians and that inequalities varied by cause of injury between rural and urban settings.9

Toddlers living in socially-deprived areas are at the greatest risk of suffering a scald in the home. Boys aged between one and two years old and those with multiple siblings are the most likely to suffer a hot water-related injury, while children born to mothers aged 40 years and over are at less risk than those with teenage mums.10

A&E attendances

Research in the Yorkshire and the Humber region showed that children from the most deprived fifth of families were 1.7 times more likely than the least deprived fifth to have had an A&E attendance for an accident. In the Kirklees area, the rate of A&E attendances was about five times higher in the most deprived fifth of the population than the least deprived fifth.11

A 2001 study of children attending an A&E department in Scotland also confirmed a trend between increased attendance among the most deprived population groups.12

Shelter’s 2006 report on the effects on children of living in bad housing states that one in four children living in unfit housing attends an accident and emergency department each year, compared to one in five of other children.4

Factors influencing accident inequalities

The reasons for childhood accident inequalities are complex but include:

  • overcrowded homes – children from overcrowded homes are three times more likely to be injured13
  • lack of money to buy safety equipment
  • lack of a garden in which children can play
  • greater exposure to through-roads and roads without parking
  • higher parental smoking rates – poorer parents are more likely to smoke, smoking is a major cause of house fires, and households with smokers are less likely to have working smoke alarms14
  • lack of accessible information – disadvantaged parents are six times more likely to have serious literacy problems; parents who are long-term unemployed, young parents and parents from deprived black and minority ethnic communities are over-represented among those with poor literacy
  • parental understanding of child development, with deprived parents more likely to be taken by surprise by the next stage of their child’s development.

There are also links to family type – teenage parents may need more support to keep their babies safe – and family size – disadvantaged parents with larger families may struggle to control their children’s behaviour.

Finally, there is an interplay between ethnicity and deprivation. Compared to white families, families from certain black and minority ethnic communities are over-represented on several indices of deprivation linked to childhood death and serious injury in preventable accidents. For example, they are:

  • seven times more likely to be living in overcrowded homes
  • up to twice as likely to be living in poverty – one in five Bangladeshi, Pakistani and Black Caribbean families live in severe hardship, compared to one in ten white families.

Some commentators have highlighted how recent spending cutbacks in local authorities may have an effect on accidental injuries among low-income children. The removal of speed camera funding, for example, can put low-income children at particular risk of road traffic accidents.15

Policy arena

Public Health Outcomes Framework

The vision for the Public Health Outcomes Framework, which was updated in November 2013, is to improve and protect the nation’s health and wellbeing, and to improve the health of the poorest fastest. The second of the two outcomes in the framework seeks to reduce differences in life expectancy and healthy life expectancy between communities, through greater improvements in more disadvantaged communities.

Accident prevention is one of the 17 key areas identified as a responsibility for local authorities within the Public Health Outcomes Framework. The framework notes that injuries disproportionately affect children from lower socio-economic groups. It includes the following indicators which relate to health inequalities and childhood accidents:

  • indicator 0.1: healthy life expectancy
  • indicator 0.2: differences in life expectancy between communities
  • indicator 1.1: children in poverty
  • indicator 1.2: school readiness
  • indicator 1.3: pupil absence
  • indicator 1.10: killed and seriously injured casualties on England's roads
  • indicator 1.15: statutory homelessness
  • indicator 1.16: utilisation of outdoor space for exercise / health reasons
  • indicator 2.4: under 18 conceptions
  • indicator 2.5: child development at 2-2.5 years
  • indicator 2.7: hospital admissions caused by unintentional and deliberate injuries in children and young people aged 0-14 and 15-24 years
  • indicator 4.1: infant mortality
  • indicator 4.3: mortality rate from causes considered preventable.

Marmot Review

The Public Health Outcomes Framework draws heavily on Fair Society, Healthy Lives: The Marmot Review of Health Inequalities in England (2010). An update to the report was released in 2012 which showed that while life expectancy had improved for most of the 150 local authority areas in England that were due to take over responsibility for public health in April 2013, inequalities in these areas had also increased.

The Marmot Review stresses the importance of taking a life-course perspective and recognising that disadvantage accumulates throughout life. It emphasises that the close links between early disadvantage and poor outcomes can only be broken by taking action to reduce health inequalities before birth, and continuing these throughout the life of the child. This is reflected in the review's“Give every child the best start in life” policy objective, which aims to give every child the best start in life in order to reduce health inequalities across the life course.

Health and wellbeing boards

The recent NHS and Social Care Act sees the lead responsibility for public health transferring from the NHS to local authorities. Newly-established health and wellbeing boards situated in local authorities are expected to be the key to unlocking the wider social determinants of health such as education, housing, employment and community safety, all of which relate to health inequalities.

Child Poverty Strategy

The Government’s Child Poverty Strategy says that: “a focus solely on household income is likely to overlook other factors that are crucial for children’s longer term development and that can compound disadvantage over time. A sustainable approach to tackling child poverty needs to address a wide range of factors such as family, home environment, health and education.”

Prevention programmes

As deprived geographical areas and deprived communities are generally known to local commissioners, accident prevention programmes can be targeted, focussing on children and families at greatest risk. Programmes can include:

  • the fire and rescue service providing home fire risk checks and fitting free smoke alarms in the homes of disadvantaged families
  • home safety equipment schemes that provide/fit free equipment such as safety gates, window locks and fireguards in the homes of vulnerable families, supported by home safety checks and home safety education and information
  • fitting thermostatic mixing valves designed to prevent serious bath water scalds in the homes of vulnerable families, for example, as part of a refurbishment programme for local authority or housing association housing
  • road safety engineering measures designed to reduce the speed of traffic in deprived areas and minimise the use of residential roads as cut-throughs
  • refurbishing a park in a deprived area to give local children outdoor play space away from roads
  • community education work, including using CAPT’s Child Safety Week campaign and our DVD education packs and Picture of Safety series of picture booklets for disadvantaged parents with low literacy or who speak English as a second language.

Engaging parents

The 2012 report An Equal Start: Improving outcomes in Children’s Centres identifies “being responsive and attentive” as a critical role for parents and explains that one of the ones this can be done is through, “setting boundaries that keep children safe while allowing them to explore their world”.

Our topic briefing on engaging with parents and carers provides more information on this area.

Family Nurse Partnership

The Family Nurse Partnership programme offers intensive and structured home visiting for vulnerable and young first-time mothers, from early pregnancy until the child reaches two years old.

Family nurses establish supportive long-term relationships with clients, building on each parent’s motivation to do the best for their child and developing the strengths within a family to promote change. How to prevent childhood accidents is one of the topics covered in the programme. Research from the USA, where the programme was developed, has shown that it successfully reduces childhood injuries.16

NHS England is responsible for doubling the number of Family Nurse Partnership clients at any one time to 13,000 and recruiting an additional 4,200 health visitors by April 2015.

Partnership working

Many agencies and professional groups have the opportunity to impact positively on injury inequalities through the support that they provide to families. Through co-ordinated working and appropriate professional training, each group can identify problems, make referrals as needed and give uniform advice. Effective co-ordination and leadership is key to the success of partnership working.

Mainstream services with opportunities to tackle accident inequalities include:

  • early years and childcare
  • health visiting
  • public health
  • road safety
  • fire and rescue service
  • local authority and housing association social housing providers.

Agencies and programmes supporting vulnerable and disadvantaged families include:

  • children’s centres
  • Family Nurse Partnerships
  • Home Start and other family support projects run by voluntary sector organisations
  • community groups working in areas of deprivation.

How Making the Link can help you

Making the Link is here to support people with a role to play in child accident prevention throughout England. We recognise that effective child accident prevention programmes and strategies happen through successful partnership working.

We’d like to hear about the work you’re doing in your area and any things that have worked well which we can share with other professionals on the Making the Link site. Email us at info@makingthelink.net to:

  • submit case studies about your child accident prevention work
  • suggest ideas for Making the Link resources that would help you in work
  • find out more about the project or any other information on the website.

Explore the Making the Link site to:

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Useful links

Making the Link site links

CAPT links

  • CAPT's Picture of Safety series:
    Pictorial booklets aimed at parents and carers but especially those with low literacy and those for whom English is a second language.

Download this topic briefing as a PDF

References for this article

  1. State of the Nation 2013: social mobility and child poverty in Great Britain, Social Mobility and Child Poverty Commission, 2013
  2. Chief Medical Officer's annual report 2012: Our Children Deserve Better: Prevention Pays, Department of Health, 2013
  3. DEFRA briefing on rural poverty in England, January 2013
  4. Against the Odds, Shelter, 2006
  5. Better safe than sorry. Preventing unintentional injury to children, Audit Commission, 2007
  6. Edwards P et al, Deaths from injury in children and employment status in family: analysis of trends in class specific death rates, BMJ, 333: 119-121, 2007
  7. Siegler V et al, Social inequalities in fatal accidents and assaults: England and Wales, 2001-03, Office for National Statistics, Health Statistics Quarterly 48, Winter 2010
  8. Hippisley-Cox J et al, Cross sectional survey of socioeconomic variations in severity and mechanism of childhood injuries in Trent 1992-7, BMJ, 324: 1132-1134
  9. Edwards P, Green J, Lachowycz K et al, Serious injuries in children: variation by area deprivation and settlement type, Arch Dis Child;93:485-489, 2008
  10. Toddlers from socially-deprived homes most at risk of scalds, study finds, University of Nottingham press release, 8 May 2013
  11. Data Bites issue 14: childhood injuries and deprivation, Yorkshire and Humber Public Health Observatory, March 2013
  12. Beattie T et al, The association between deprivation levels, attendance rate and triage category of children attending a children’s accident and emergency department, Emergency Medicine Journal 18(2) 110-111, 2001
  13. Alwash, R and McCarthy, M, Accidents in the home among children under 5: ethnic differences or social disadvantage? British Medical Journal 296: 1450-3, 1998
  14. Rowland D, DiGuiseppi C, Roberts I et al,Prevalence of working smoke alarms in local authority inner city housing: randomised controlled trial. BMJ, 325: 998–1001, 2002
  15. Ridge T, ‘We are all in this together?’ The hidden costs of poverty, recession and austerity policies on Britain’s poorest children, Children & Society volume 27, issue 5, September 2013
  16. The Family Nurse Partnership in England – Third Year Report, Department of Health, 2011
Updated December 2013