2.1 Why focus on poverty

• The case for eradicating child poverty is not just a matter of promoting health and well-being but concerns issues of social justice, human rights and child citizenship. (UN, A World Fit for Children, 2002, Lister R, 2004)


• The UN Convention on the Rights of the Child includes the right to:


• The enjoyment of the highest attainable standard of health (Article 24)


• A standard of living adequate for the child’s physical, mental, spiritual, moral and social development (Article 27)


• Engage in play and recreational activities appropriate to the age of the child and to participate freely in cultural life and the arts (Article 31)


• Growing up in poverty damages children’s health and well-being, adversely affecting their future health and life chances as adults. Ensuring a good environment in childhood, especially early childhood, is important. A considerable body of evidence links adverse childhood circumstances to poor child health outcomes and future adult ill health. (Bradshaw et al 2004, Bradshaw 2001, Blane 1999, Graham et al 2004, Davey Smith et al 1998, Kuh et al 1997, Kuh 2004, Approach to Chronic Disease Epidemiology OUP, Kuh et al 2002).

2.2 The growth of child poverty in the UK

Child poverty is associated with widening inequalities in income, wealth and earnings.

• Child poverty is a major problem for the UK. In 2002/03, 3.6 (28 %) million children were living in income poverty (ONS 2003). This compares with 1.9 million (14 %) of children in 1979 (CPAG 2004).


• Child poverty more than doubled in the UK between 1979 and the early 1990’s. (Supplementary Figures 1 and 2)


• This huge rise accompanied a dramatic growth in income inequality (Supplementary Figures 3 and 4), wealth inequality (Supplementary Figures 5 and 6) and in earnings dispersion (that between low pay and high pay).


• Children suffered disproportionately. Poverty was concentrated in certain groups and children were affected more than the general population, particularly children living in single parent households. (Supplementary Figures 7 and 8)

By international standards the comparative picture of child poverty in the UK has been poor.

• This pattern of worsening inequality seen in the UK and USA in the last quarter of a century was not a global phenomenon. (Supplementary Figure 9)


• In 1999 the UK had the worst child poverty rate in the EU. (Supplementary Figure 10) An analysis of 29 OECD countries showed that the UK child poverty rate of almost 30% was below only that in Italy and Spain (out of 12 EU members) and twice that in the U.S.A. Thus despite being a comparatively rich country, a larger proportion of British children were poor than in most comparable countries during the mid 1990’s. (Supplementary Figure 11)


• An analysis of 12 EU Countries using the latest available Luxembourg Income Survey (web page ref. i) child poverty data (1999) and EU social cohesion indicators (web page ref. ii) shows the UK had the highest levels of child poverty, and children living in jobless households, the 2nd highest income inequality after social transfers, and the 3rd highest levels of persistent poverty, despite having lower unemployment rates. (Supplementary Figure 12)


• Evidence from international surveys suggests that poverty in the UK is more likely to be long term or repeated poverty (Hills 2004), that is those in low paid employment stay in it longer and children appear to escape poverty more slowly. (web page ref. ii)

Intergenerational economic mobility has worsened

• The increased social mobility seen over the 20th century up until the 1950’s has now reversed. The 1958 and 1970 birth cohorts show reduced intergenerational mobility. Today income and social class is more strongly related to parental earnings and social position than those born between 1940 and 1970. A mechanism driving the fall of economic mobility appears to be the increased importance of educational qualifications in explaining peoples relative earnings combined with the success of better off parents in ensuring that their children gain those qualifications. (Supplementary Figures 13,14,15)

Social policy failed to protect children in the UK

• International variation in child poverty levels shows that child poverty is not inevitable. The tax and benefit system can offset rising earnings dispersion and in some countries it has done so; in the UK and USA it has not. In other countries experiencing similar demographic changes and economic pressures to the UK, children have been protected from escalating child poverty by social policy favouring progressive taxation, higher spending on social protection for children (Devereux S et al 2004), and regulation. (Supplementary Figures 16 and 17)

Child poverty is now beginning to fall

• After peaking in 1997/1998 child poverty has fallen only slowly and remains far higher than it was a generation ago. This reduction of child poverty levels to 21% (BHC) and 28% (AHC) in 2003 accompanies a reduction in deprivation indicators for lone parents. The Households Below Average Income report shows that child poverty has been reduced by 500,000 since 1997 (Dept. for Work & Pensions 2003). However independent research has suggested that following the Blair administration’s initial reforms, some of the poorest children, approximately 300,000 or nearly 1 in 6 children, had become worse off (Dept for Work and Pensions 2003).


• Children at particular risk of continuing poverty are those who do not live in neighbourhoods benefiting from area based initiatives (ABIs), high need groups such as disabled children, asylum seeking children, homeless children, and children living in families whose parents are sick or disabled, or who are in serious debt or who are not taking up means-tested benefits.

2.3 Drivers of child poverty

• Three major factors - demographic change, labour market conditions and social policy, are the principal drivers of poverty and social exclusion in the UK (Bradshaw et al 2004). Of these social policy is the most important determinant of how demographic and labour market changes affect the circumstances of children. The scale and structure of social spending and the taxes that pay for it have major effects on income and wealth distribution. Interventions to improve inequalities in child outcomes and future adult health are more effective when they focus on the pathways linking childhood poverty, child health and adult health, and on the material and social conditions in which they are embedded (Graham et al 2004). Mainstream welfare agencies play an important role in both determining the material circumstances in which poor children live and on children’s developmental health, educational and social trajectories. (Graham et al 2004)

	Figure 02.01 The link between child poverty, the most powerful determinant of childhood disadvantage and its outcomes.
	Table 02.01 Factors which increase the risk of child poverty and its associated adverse outcomes.

2.4 Pathways of transmission

• Childhood poverty affects both child health and adult health through a set of interlocking processes: children’s physical, cognitive and emotional development and the development of their health behaviours are shaped by their living context (e.g. family, social networks, neighbourhood (infrastructure, services, etc) and wider society) and by their endogenous capacities / vulnerabilities (eg. genetics, biology, disability, ethnicity, personality and resilience).


• Beneficial and adverse exposures over the life course will vary for each individual. The pattern of exposures creates different expressions of health and well being for a particular individual.


• Childhood is a time when educational and social trajectories are particularly important and when cultural norms and patterns of behaviour are established.


• Childhood disadvantage experienced across critical periods of development can lead to poor adult health (Supplementary Figure 18)

2.5 Adverse outcomes associated with child poverty

• Disadvantaged childhood conditions have both direct and indirect impacts on child health and adult health. Table 2.2 summarises the trends over the last two decades for child poverty and its outcomes. (Bradshaw 2001)

• Some outcomes have not deteriorated with the increasing child poverty over the last two decades. For example, infant mortality has been reduced by improvements in infant care, dental health by fluoridation of drinking water, fatal accidents by prevention policies and reduced freedom to roam, teenage pregnancy by sex education, contraception and abortion and bad housing by housing improvements, educational attainment by investment in standards.


• In contrast for outcomes, which have worsened or seen inequalities widen:


• Part of the increase in low birth weight (LBW) is associated with increased births among black minority ethnic (BME) groups, and an increased ability to keep premature babies alive.


• Accidental deaths are the main cause of child deaths and poorer children are more likely to die on the roads and from accidents at home.


• Homelessness is a crisis almost entirely restricted to the poor by definition; housing policy, which has affected affordability and availability, has restricted access to social housing.


• Although standards in schools may be improving overall, differentials in standards and hence the quality of education provided by schools, are increasing. Academic achievement is also directly related to pupil factors such as socio-economic background (NAO 2003) and is therefore likely to be worse for children living in poverty.


• School exclusions are difficult to interpret and may be partly driven by the standards agenda and individual school policy


• Differential prevalence by socio-economic group for childhood obesity may be partly related to the difficulty poor families experience in affording ‘health enhancing’ food, especially fresh fruit and vegetables, compared to the relative cheapness of energy dense, high-fat, high-sugar, high-salt processed foods. (Dobson and Kellard 2000, Dowler et al 1995, Dowler 2001, Nelson et al 2004)

2.6 Child poverty in the West Midlands

• The choice of variables and indicators used to measure child poverty and its outcomes is not straightforward, as highlighted in the extensive literature concerning the complexity of the methodological issues. (Carr-Hill, SWPHO PAT18, Barnes 2001, Dept for Work & Pensions 2003). Poverty is a contested concept and the subject has generated enormous debate and literature. Numerous definitions of poverty reflect not only historical development but also tensions between differing explanations of its causes and what needs to be done to alleviate or eliminate it. Measuring poverty is thus ‘fraught with problems and disagreements’. (Alcock 1997)


• Children in Britain can be said to live in poverty when they live in families, which lack the resources to enable their children to participate in the activities and have the living conditions and amenities, which are customary, or at least widely encouraged or approved. They are effectively excluded from ordinary living patterns, customs and activities. (House of Commons 2004). Child poverty is an aspect of family poverty and is closely related to the concepts of deprivation, social exclusion, inequality, inequity and social polarisation.


• Indicators used to measure poverty include: (SWPHO PAT18)


• Income/expenditure


• Wealth


• Proxies for financial resources


• Social assistance


• Deprivation indicators


• Absence of socially defined necessities


• Subjective measures on adequacy of resources


• The UK government uses three main official sources of data on child poverty and social exclusion in Britain. (Plewis et al 2001)


• Households Below Average Income Statistics (HBAI) - derived from an analysis of Family Resources Survey and British Household Panel Survey) (web page ref. iii)


• Annual Report on poverty and social exclusion – Opportunity For All (web page ref. iv)


• National Action Plan on Social Exclusion (web page ref. v)


• In future child poverty will be measured using 3 indicators:


• Absolute low income – to measure whether the very poorest families are seeing their incomes rise in real terms. Indicator: the number of children living in families with incomes below a particular threshold which is adjusted for inflation – set for a couple with one child at £210.50 a week in today’s terms.


• Relative low income – to measure whether the poorest families are keeping pace with the growth of incomes in the economy as a whole. Indicator: number of children living in households below 60 per cent of contemporary median equivalised household income.


• Material deprivation and low income combined – to provide a wider measure of people’s living standards. Indicator: The numbers of children living in households that are both materially deprived (lacking certain goods and services (Family Resource Survey 2004)) and have an income below 70 per cent of contemporary median equivalised household income.


• The relative low-income statistic (HBAI) is available and regularly published (unlike the other two indicators). However, it is only available at national and regional levels. Therefore to map child poverty at local area level and show how it varies across the West Midlands region, the following have been used:


• IMD 2000 Child Poverty Index (Figure 2.2) – which measures families in receipt of means tested benefits


• ID 2004: The Supplementary Income Deprivation Affecting Children (Figure 2.3)


• % of pupils who are eligible or accessing free school meals 2003/04 (Figure 2.4)


• Number of homeless households with dependent children eligible for temporary accommodation 2004 (Figure 2.5, Table 2.4)

	Figure 02.02 Map to show West Midlands IMD 2000 Child Poverty Index.
	Figure 02.03 Map to show West Midlands IMD 2004: The Supplementary Income Deprivation Affecting Children.
	Figure 02.04 Percentage of pupils who are eligible or accessing free school meals 2003/04 by West Midlands LEA.
	Table 02.03 Free School meal arrangements by Local Education Authority, All Schools, Academic year 2003/04.
	Figure 02.05 West Midlands Homelessness affecting children, Number of homeless households with dependent children eligible for temporary accommodation 2004.
	Table 02.04 West Midlands Homelessness affecting children, Number of homeless households with dependent children eligible for temporary accommodation 2004

2.7 Child outcomes associated with child poverty in the West Midlands

• The selected indicators are those which have shown widening inequality by socioeconomic group over the last two decades or which have been historically high for the West Midlands (teenage pregnancy and infant mortality).

2.7.1 Low Birth Weight

• Low birth weight (LBW) is defined as a birth weight of less than 2,500g. LBW contributes substantially to both infant mortality and to childhood physical impairment. It is caused by either a short gestation period or retarded intrauterine growth (or a combination of both).


• LBW babies account for around 7% of all live births (7.48% in 1998, England and Wales). LBW varies widely according to socio-economic status e.g. 5.4% in professional social class I (based on the occupation of the father) compared with 8.2% in unskilled social class V and 9.3% of births registered by the mother alone (1991-1995 data).


• This social gradient is also paralleled, and often confounded by, marked ethnic differences in LBW prevalence. Higher rates of LBW are to be found among Asian women in the UK.


• Forty per-cent of the deaths in LBW babies occur in infants less than 1500 grams (Very low birth weight, VLBW), with the highest death rate taking place in extremely low birth weight (ELBW) infants who weigh less than 1000 grams Although the causes of ELBW and VLBW infant births differ from that of LBW infants in some regards, there may be significant overlap especially in the impact of psychosocial and environmental factors.


• The exact causes of LBW are not known. Although not the total picture, three major risk factors account for a large proportion of all LBW births: cigarette smoking during pregnancy, low maternal weight gain and low pre-pregnancy weight. Other modifiable risk factors include infection, poverty, poor social support, poor housing, poor community resources, alcohol-use during pregnancy and exposure to violence.

	Figure 02.06 Variation in low birth weight across the West Midlands.
	Table 02.05 Variation in low birth weight across the West Midlands.

2.7.2 Infant Mortality

• Infant mortality is defined as the number of infant deaths (under 1 year of age) per 1000 live births. Infant mortality shows a strong social class gradient in the UK, with differentials greater in the post-neonatal period than for the peri- and neonatal periods.


• Infant mortality rates are related to deprivation – with higher rates occurring in more deprived areas. In the under 1’s, deaths due to Sudden Infant Death Syndrome (SIDS) predominate in post neonatal period whereas in the first month of life deaths due to the consequences of prematurity predominate.

	Figure 02.07 Variation in infant mortality across the West Midlands.
	Table 02.06 West Midlands infant mortality rates per 1,000 live births (2000-2002).

2.7.3 Hospital Admission Rates For Severe Accidental Injury In Children

• There is generally a strong relationship between deprivation and childhood accident fatality and hospital admissions for injury. Childhood accident mortality in the UK is low by international comparison, having declined over the last 20 years but death from injury or poisoning remains the leading cause of death for children under 15 years of age in the UK.


• Causes of injury death vary by age group. The highest cause-specific injury death rate among adolescents aged 15–19 involves motor vehicle occupants. For children aged 5–9 and 10–14, pedestrian injury is responsible for the highest death rates. For children aged 1–4, fire and flames and pedestrian injury show the highest cause specific death rates. Among children under 1 year of age, the most important cause of injury death is suffocation, most of which involves inhalation or ingestion of poisons. (Roberts et al 1998) Environmental factors and rates of exposure play an important role in accounting for differences in mortality and morbidity. Poorer children are more likely to live in built-up areas with high traffic volume and are more likely to be without a family car, putting them at greater risk of being a pedestrian victim of a car accident.

	Figure 02.08 Variation in hospital admission rates for serious accidental injury in children across the West Midlands.
	Table 02.07 West Midlands hospital admission rates for severe accidental injury in children.

2.7.4 Educational Attainment

• Educational attainment is a powerful childhood predictor of adult outcomes such as: (Bradshaw et al 2004, Bradshaw 2001)


• Poorer access to the labour market


• Higher risk of spells of unemployment


• Lower earnings


• Not owning a home


• Poorer reported general health


• Depression


• Lower probability of voting in general elections


• One measure of educational attainment used to monitor progress in educational policy is the percentage of 15-year-old pupils achieving 5 GCSEs (A*-C).


• The relationship between educational attainment and child poverty is complex.


• International comparisons of educational attainment and disadvantage shows:


• educational performance in some countries is consistently better than in others – whether measured by the percentage of students reaching fixed benchmarks of achievement or by the size of the gap between low-achieving and average students. (UNICEF 2002)


• variation between schools in educational performance is much higher in some countries than in others. (UNICEF 2002)


• there is no simple relationship between the level of educational disadvantage in a country and educational spending per pupil, pupil: teacher ratios, or degree of income inequality. (UNICEF 2002)


• In all countries, educational achievement remains strongly related to the occupations, education and economic status of the student’s parents, though the strength of that relationship varies from country to country.


• In the UK the association between social class and educational attainment is much stronger and the tail of under-achievement longer than in other developed nations. Inequality in learning achievement begins at an early age and attempts to mitigate educational disadvantage need to begin even before a child starts school through good quality early childhood care and education


• There is considerable variation in educational attainment between schools with a similar proportion of disadvantaged children attending (as measured by Free School Meal Entitlement). Educational attainment depends on both the quality of education provided by a school and child/family characteristics such as socio-economic circumstances. The relative importance of school or background is contested: some studies conclude that non-school factors are more important than the type and quality of schooling (Sparkes 1999) whilst others find school quality makes a far larger contribution to educational progress than child background (Mortimer et al 1988), and yet others find school and background to be about equally important. (Sammons et al 1997) Some of this variation may be due to the inverse care law operating in schools. An analysis of OFSTED inspection data from 1996-2001 found a clear relationship between areas of deprivation and school quality: the more deprived the area in which a school is located, the poorer the school quality is likely to be. (Lupton 2002)

	Figure 02.09 Variation in educational attainment across the West Midlands.
	Table 02.08 Educational attainment across the West Midlands, Percentage of 15 year old pupils achieving GCSE and equivalents.

2.7.5 Teenage Pregnancy

• The UK has the highest teenage pregnancy rate in Europe, with more than 90,000 teenagers becoming pregnant each year in England. Thirty seven per cent of conceptions among people under 20 end in an abortion. (Bradshaw et al 2004)


• Many teenage mothers have grown up with some degree of poverty or disadvantage and have little in the way of educational qualifications or career prospects – factors that are likely to have negative effects on their future lives, particularly the risk of living in poverty.


• Teenage mothers are likely to be dependent on the state, have high rates of postnatal depression and low take-up of breast feeding, are less likely to finish their education or training, less likely to find employment, and are more likely to end up as a lone parent, bringing up their children in poverty.


• Children from teenage parents have a much greater risk of poor health, increased risk of: anaemia, pregnancy-induced hypertension, prematurity, lower birth weights, intra-uterine growth retardation, infant mortality, some congenital anomalies. They are also more likely to be teenage parents themselves.


• There are three main reasons for teenage pregnancy rates being so high in the UK: low expectations, ignorance and mixed messages about sex. (Bradshaw et al 2004).

	Figure 02.10 Variation in teenage conceptions across the West Midlands.
	Table 02.09 Variation in teenage conceptions across the West Midlands.

2.7.6 School Exclusions

• The incidence of exclusion is on the increase. Exclusions fall disproportionately on boys in general, African-Caribbean boys in particular, children with statemented special needs, and children and young people in care.


• Exclusion and truancy are not insoluble problems. Some schools with broadly similar intakes and academic performance are achieving much lower levels of truancy and exclusions than others, suggesting that variation in school exclusion rates reflect quality of educational practice.


• Being excluded from school is damaging to children: truancy and exclusion are associated with a significantly higher likelihood of poor educational attainment, becoming a teenage parent, being unemployed or homeless later in life, or ending up in prison. The wider community suffers because of the high levels of crime into which many truants and excluded pupils get drawn. (Soc. Exc. Unit 1998) There is a direct link between time lost from education and crime in later life, with a third of all prisoners having been regular truants from school and half of all male prisoners having been excluded from classes. (web page ref. vi)

	Figure 02.11 Variation in school exclusions across the West Midlands.
	Table 02.10 Variation in school exclusions across the West Midlands.

2.7.7 Suicide In Young People

• The suicide rate in young men had shown a substantial increase between the early 1970s and its peak in 1998. Since then there has been a sustained fall of nearly 30% to a rate equivalent to that seen in the mid 1980s.


• Suicidal behaviour tends to be more common amongst people from backgrounds characterised by low socio-economic status, limited educational achievement and low income.


• Suicide by young people has been associated with a number of social and interpersonal factors such as being unemployed, socially isolated, unmarried, and recent interpersonal life events or difficulties with parents, peers or partners. (Appleby et al 1999)


• Significant associations between unemployment and suicide in both males and females, aged 15-44, have been found with the strongest associations among younger men and women. (Gunnell et al 1999)


• In general, adolescent suicide attempters appear to grow up in families with more turmoil than other groups of adolescents, coming more often from broken homes (due to death or divorce), homes where there is parental unemployment, mental illness, or addiction.

	Figure 02.12 Variation in rates for Suicides and Undetermined Injury, Aged 15-34, 1998-2002 across the West Midlands.
	Table 02.11 Variation in suicide rates in young people across the West Midlands.

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